description,transcription,sample_name,medical_specialty,keywords
Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,"PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.",Pacemaker Interrogation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,"
"Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.","PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:,  Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee.  He has been to multiple institutions as an outpatient for this complaint.  He has had what appears to be prepatellar bursa aspirated with little to no success.  He has been treated with Kefzol and 1 g of Rocephin one point.  He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful.  Orthopedic Surgery was consulted at this time.  Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee.  After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE:  ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella.  The 20-gauge spinal needle was inserted and entered the knee joint.  Approximately, 4 cc of clear yellow fluid was aspirated.  The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint.  We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain.  We will follow these results.  After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.",Aspiration - Knee Joint,Orthopedic,"orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion,"
Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina.,"PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.",Cardiac Cath & Selective Coronary Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,"
"Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.","REASON FOR VISIT: , Acute kidney failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min.  The patient had blood work done at Dr. XYZ's office on June 01, 2006, which revealed an elevation in his creatinine up to 2.3.  He was asked to come in to see a nephrologist for further evaluation.  I am therefore asked by Dr. XYZ to see this patient in consultation for evaluation of acute on chronic kidney failure.  The patient states that he was actually taking up to 12 to 13 pills of Chinese herbs and dietary supplements for the past year.  He only stopped about two or three weeks ago.  He also states that TriCor was added about one or two months ago but he is not sure of the date.  He has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on Flomax.  He states that his urinary dribbling and weak stream had not improved since doing this.  For the past couple of weeks, he has had dizziness in the morning.  This is then associated with low glucose.  However the patient's blood glucose this morning was 123 and he still was dizzy.  This was worse on standing.  He states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions.  His pulses remained in the 60s.,ALLERGIES: , None.,MEDICATIONS: , Imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, Zetia 10 mg daily, ? Triglide 50 mg daily, Prevacid 30 mg daily, Plavix 75 mg daily, potassium 10 mEq daily, Lasix 60 mg daily, folate 1 mg b.i.d., Niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., Xanax 0.25 mg b.i.d., aspirin 325 mg daily, Tylenol p.r.n., Zantac 150 mg b.i.d., Crestor 5 mg daily, TriCor 145 mg daily, Digitek 0.125 mg daily, Celexa 20 mg daily, and Flomax 0.4 mg daily.,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post CABG x 5 in December 2001.,2.  Three stents last placed approximately 2002.,3.  Heart failure, ejection fraction of 30%.,4.  Hypertension since 1985.,5.  Diabetes since 1985 with history of laser surgery.,6.  Moderate mitral regurgitation.,7.  GI bleed.,8.  Hyperlipidemia.,9.  BPH.,10.  Back surgery.,11.  Sleep apnea.,SOCIAL HISTORY: , He is a former tailor from Korea.  He is divorced.  He has one daughter who has brain injury status post severe seizure as a child.  He is the primary caregiver.  No drug abuse.  He quit tobacco and alcohol 15 years ago.,FAMILY HISTORY: , Parents both died in Korea.  Has one sister with hypertension and the other sister lives in Detroit and is healthy.,REVIEW OF SYSTEMS: , He has lost about 10 pounds over the past month.  He has been fatigue and weak with no appetite.  He has occasional chest pain and dyspnea on exertion on fast walking.  His lower extremity edema has improved with higher doses of furosemide.  He does complain of some early satiety.  He complains of urinary frequency, nocturia, weak stream and dribbling.  He has never passed the stone.  He gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s.  He has some right back pain today and complains of farsightedness.  The remainder of review of systems is done and negative per the patient.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 78.  Blood pressure 116/60.  Height 5'7"" per the patient.  Weight 78.6 kg.  Supine pulse 60 with blood pressure 128/55.  Standing pulse 60 with blood pressure of 132/50.  GENERAL:  He is in no apparent distress, but he is dizzy on standing for prolonged period.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements are intact.  Sclerae not icteric.  HEENT:  He wears upper and lower dentures.  Lips acyanotic.  Hearing is grossly intact.  Oropharynx is otherwise clear.  NECK:  Supple.  No JVD.  No bruits.  No masses.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Active bowel sounds.  Soft, nontender, and nondistended.  No suprapubic tenderness.  EXTREMITIES:  No clubbing, cyanosis or edema.  MUSCULOSKELETAL:  5/5 strength bilaterally.  No synovitis, arthritis or gait disturbance.  SKIN:  Old scars in his low back as well as his left lower extremity.  No active rashes, purpura or petechiae.  Midline sternotomy scar is well healed.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Reflexes are poor to 1+ bilaterally.  10 g monofilament sensation is intact except for the big toes bilaterally.  No asterixis.  Finger-to-nose testing is intact.  PSYCHIATRIC:  Fully alert and oriented.,LABORATORY DATA:,  December 2004, creatinine was 1.5.  Per report May 2006, creatinine was 1.8 with a BUN of 28.  Labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, CO2 25, BUN 46, creatinine 2.3, glucose 162, albumin 4.7, LFTs are normal.  CK was elevated at 653.  A1c is 7.6%.  LDL cholesterol is 68, HDL is 35.  Urinalysis reveals microalbumin to creatinine ratio 59.8.  UA was otherwise negative with a pH of 5.  Today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dL of protein, pH of 5, negative nitrates, leukocyte esterase.  Microscopic exam was bland.,IMPRESSION:,1.  Acute on chronic kidney failure.  He has underlying stage III CKD with the GFR approximately 41 mL/min.  He has episodic hypotension at home and low diastolic pressure here.  His weight is down 2 to 3 Kg from June and he may be prerenal.  He also has a history of prostatic hypertrophy and obstruction must be investigated.  I am also concerned about his use of Chinese herbs which can cause chronic interstitial nephritis.  There is no evidence of pyuria today although this can present with a fairly bland sediment.  An additional concern is that TriCor can cause an artifactual increase in the creatinine due to changes in metabolism.  I think this would be a diagnosis of exclusion.,2.  Orthostatic hypotension.  He is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.,3.  Elevated creatine kinase consistent with myositis.  It could be a result of Crestor alone or combination of TriCor and Crestor.  I do not think this is enough to cause rhabdomyolysis, however.,RECOMMENDATIONS:,1.  The patient was cautioned about using NSAIDs and told to avoid any further Chinese herbs.,2.  Recheck labs including CBC with differential, SPEP, uric acid and renal panel.,3.  Decrease atenolol to 25 mg daily.,4.  Decrease enalapril to 10 mg daily.,5.  Decrease Lasix to 20 mg daily.,6.  Stop Crestor.,7.  Check renal ultrasound.,8.  See him back in two weeks for review of the studies.",Acute Kidney Failure,Nephrology,
Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,"REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.",Cardiac Consultation - 6,Cardiovascular / Pulmonary,
Vaginal discharge with a foul odor.,"CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,",Gardnerella Bacterial Vaginosis,Obstetrics / Gynecology,
"He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again.","HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , 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:  BP 124/76",Diplopia,Ophthalmology,
Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.,"PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.",Flex Sig - 2,Gastroenterology,"gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",Lumbar Puncture,Neurology,
Right ear pain with drainage - otitis media and otorrhea.,"CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.",Ear Pain - Drainage,ENT - Otolaryngology,"ent - otolaryngology, drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,"
"Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.","PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.",Laparoscopic Pyeloplasty,Nephrology,"nephrology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,"
Patient with a history of right upper pons and right cerebral peduncle infarction.,"FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.",Consult - Cerebral Peduncle Infarction,Neurology,"neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,"
A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain.  MI has been ruled out.  She has been referred for an exercise echocardiogram.,"Informed written consent has been obtained from the patient.  I explained the procedure to her prior to initiation of such.  The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position.  There were no safety concerns noted by staff nor myself.,REST ECHO:,  EF 60%.  No wall motion abnormalities.  EKG shows normal sinus rhythm with mild ST depressions.  The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen.  Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities.  There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise.  No dysrhythmias noted.,IMPRESSION:,1.  Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2.  Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient.  Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.",Exercise Stress Test - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram"
"The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.","IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is ""back to normal."" She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as ""okay."",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.",Psych Consult - Assaultive Behavior,Psychiatry / Psychology,
Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,"DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.",Aortic Valve Replacement,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,"
"A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.","HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma.  Father is alive, but unknown medical history as they have been estranged.  She has a 51-year-old sister with history of multiple colon polyps.  She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history.  To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago.  She is divorced.  She has worked as a travel agent.  She has 2 sons ages 24 and 26, both of whom are alive and well.  She smokes a half a pack of cigarettes per day for more than 35 years.  She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated.  Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION:  ,Weight 152 pounds.  Height is 5 feet 3 inches.  Blood pressure 136/80.  Pulse 68.  In general:  She is a well-developed and well-nourished female who ambulates with the assistance of a cane.  Neurologically nonfocal.  Awake, alert, and oriented x 3.  HEENT:  Head normocephalic, atraumatic.  Sclerae anicteric.  Conjunctivae are pink.  Mouth is moist without any obvious oral lesions.  Neck is supple.  There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable.  Lungs are clear to auscultation bilaterally.  Heart:  Regular rate and rhythm without obvious gallops or murmurs.  Abdomen is soft, nontender with good bowel sounds.  No organomegaly or masses are appreciable.  Extremities are without clubbing, cyanosis, and/or edema.  Skin is warm and dry.  Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1.  A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2.  Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year.  Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3.  Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation.  She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4.  A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids.  She may likely have underlying gastroesophageal reflux disease.,5.  A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds.  She may also have some GI dysmotility including gastroparesis.,6.  Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine.  If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia.  Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7.  A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology.  She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases.  She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1.  We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases.  She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2.  Discussed reflux precautions and gave literature for further review.,3.  Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids.  Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4.  Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5.  Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination.,",Consult - Multiple Colon Polyps,Gastroenterology,"gastroenterology, mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps,"
"Patient with atrial fibrillation with slow ventricular response, partially due to medications.","HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.",Cardiac Consultation - 3,Cardiovascular / Pulmonary,
"Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.","CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.",CT Abdomen & Pelvis - 8,Gastroenterology,"gastroenterology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen"
MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",MRI Spine - Epidural Lipoma,Neurology,
The patient was exercised according to standard Bruce protocol for 9 minutes.,"REASON FOR EXAMINATION:,  Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate.  Peak blood pressure was 132/60.  The patient did not experience any chest discomfort during stress or recovery.  The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram.  Technetium was injected at 5 minutes into stress.,IMPRESSION:,1.  Good exercise tolerance.,2.  Adequate heart rate and blood pressure response.,3.  This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,",Treadmill Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram,"
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.",Chest Tube Insertion in ER,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,"
Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,"CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.",Cerebral Angiogram,Neurology,
"Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter.  Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.","PREOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,PROCEDURE PERFORMED:,1.  Insertion of a right brachial artery arterial catheter.,2.  Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis.  She was severely dehydrated and necessitated some fluid boluses.  The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  She required intubation and has been ventilator-dependent in the Intensive Care since that time.  The patient developed very high temperatures as well as leukocytosis.  Her lines required being changed.,PROCEDURE:,1.  RIGHT BRACHIAL ARTERIAL LINE:  ,The patient's right arm was prepped and draped in the usual sterile fashion.  There was a good brachial pulse palpated.  The artery was cannulated with the provided needle and the kit.  There was good arterial blood return noted immediately.  On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery.  The femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  We did not feel that the shorter catheter would provide enough length.  The catheter was connected to the system and flushed without difficulty.  A good waveform was noted.  The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2.  RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER:  ,The patient was prepped and draped in the usual sterile fashion.  1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  We roughed the needle down off the clavicle and directed it towards the sternal notch.  There was good venous return noted immediately.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein.  The needle was then removed.  A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  Next, the triple lumen catheter was inserted over the guidewire without difficulty.  The guidewire was removed.  All the ports aspirated and flushed without difficulty.  The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied.  The patient tolerated the above procedures well.  A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.",Triple Lumen Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle,"
"Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.","EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.",Chest Pulmonary Angio,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio"
"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.","PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",Facetectomy & Foraminotomy,Orthopedic,
"Left and right heart catheterization and selective coronary angiography.  Coronary artery disease, severe aortic stenosis by echo.","INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.",Heart Catheterization & Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary"
"The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.","IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is ""back to normal."" She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as ""okay."",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.",Psych Consult - Assaultive Behavior,Psychiatry / Psychology,
"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Akin bunionectomy, right toe with internal wire fixation.","PREOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux valgus, right foot.,2.  Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Akin bunionectomy, right toe with internal wire fixation.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 51-year-old female presents to ABCD preoperative holding area after keeping herself NPO since mid night for a surgery on her painful bunion through her right foot.  The patient has a history of gradual onset of a painful bunion over the past several years.  She has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with Dr. X all of which have provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the Webril.,After adequate IV sedation was administered by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 0.5% Marcaine plain and 1% Lidocaine plain was injected into the foot in a standard Mayo block fashion.  The foot was elevated off the table.  Esmarch bandages were used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and the sterile stockinet was reflected.  A sterile Betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate.  Attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion.  A #10 blade was used to make a 4 cm dorsolinear incision.  A #15 blade was used to deepen the incision through the subcutaneous layer.  All superficial subcutaneous vessels were ligated with electrocautery.  Next, a linear capsular incision was made down the bone with a #15 blade.  The capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound.  A hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head.  The medial plantar aspect of the metatarsal head had some erosive changes and eburnation.  Next, a 0.45 inch Kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it.  A sagittal saw was used to make a long-arm Austin osteotomy in the usual fashion.  Standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,The capital head was shifted laterally and impacted on the residual metatarsal head.  Nice correction was achieved and excellent bone to bone contact was achieved.  The bone stock was slightly decreased, but adequate.  Next, a 0.45 inch Kirschner wire was used to temporarily fixate the metatarsal capital fragment.  A 2.7 x 18 mm Synthes cortical screw was thrown using standard AO technique.  Excellent rigid fixation was achieved.  A second 2.0 x 80 mm Synthes fully threaded cortical screw was also thrown using standard AO technique at the proximal aspect of the metatarsal head.  Again, an excellent rigid fixation was obtained and the screws were tight.  The temporary fixation was removed.  A medial overhanging bone was resected with a sagittal saw.  The foot was loaded and the hallux was found to have an interphalangeus deformity present.,A sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge.  A distal cut parallel with the nail base was performed and a standard proximal Akin osteotomy was done.,After the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy.  A #15 drill blade was used to drill two converging holes on the medial aspect of the bone.  A #28 gauge monofilament wire was inserted loop to loop and pulled through the bone.  The monofilament wire was twisted down and tapped into the distal drill hole.  The foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved.  Next, reciprocating rasps were used to smooth all bony surfaces.  Copious amounts of sterile saline was used to flush the joint.  Next, a #3-0 Vicryl was used to reapproximate the capsular periosteal tissue layer.  Next, #4-0 Vicryl was used to close the subcutaneous layer.  #5-0 Vicryl was used to the close the subcuticular layer in a running fashion.  Next, 1 cc of dexamethasone phosphate was then instilled in the joint.  The Steri-Strips were applied followed by standard postoperative dressing consisting of Owen silk, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She is to be partial weightbearing with crutches.  She is to follow with Dr. X.  She was given emergency contact numbers and instructions to call if problems arise.  She was given prescription for Vicodin ES #25 one p.o. q.4-6h. p.r.n. pain and Naprosyn one p.o. b.i.d.  500 mg.  She was discharged in stable condition.",Bunionectomy & Osteotomy,Orthopedic,"orthopedic, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal"
"Congestive heart failure (CHF).  The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.","REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.  Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS:  ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:,  Married, active smoker, does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above.  The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of blurry vision and hearing impaired.  No glaucoma.,CARDIOVASCULAR:  Shortness of breath, congestive heart failure, and arrhythmia.  Prior history of chest pain.,RESPIRATORY:  Bronchitis and pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Non-significant.,NEUROLOGICAL:  No TIA.  No CVA or seizure disorder.,ENDOCRINE:  Non-significant.,HEMATOLOGICAL:  Non-significant.,PSYCHOLOGICAL:  Anxiety.  No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART:  PMI displaced.  S1 and S2, regular.  Systolic murmur.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Trace edema of the ankle.  Pulses are feebly palpable.  Clubbing plus.  No cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect.  Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7.  INR 1.8.  BUN and creatinine within normal limits.  Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:",Consult - Congestive Heart Failure,Cardiovascular / Pulmonary,
Right radical nephrectomy and assisted laparoscopic approach.,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.",Nephrectomy - Radical,Nephrology,"nephrology, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical,"
Laparoscopic bilateral tubal ligation with Falope rings.,"DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.",Tubal Ligation,Obstetrics / Gynecology,"obstetrics / gynecology, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope"
A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,"REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA:",Hepatic Encephalopathy,Neurology,
"The patient with gradual onset of a headache problem, located behind both eyes.","CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:",Migraine without Aura - Consult,Neurology,
MRI left knee without contrast.,"EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.",MRI Knee - 4,Orthopedic,"orthopedic, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament"
Leaking anastomosis from esophagogastrectomy.   Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage.,"PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.",Exploratory Laparotomy,Gastroenterology,"gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach"
Psychosocial Evaluation of patient before kidney transplant.,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",Psychosocial Eval for Kidney Transplant,Nephrology,
"A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.","CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-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.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No",Otitis Media - H&P,Pediatrics - Neonatal,
"Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft.  Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.","PREOPERATIVE DIAGNOSES:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1.  Chronic renal failure.,2.  Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1.  Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula.,2.  Revision of distal anastomosis with 7 mm interposition Gore-Tex graft.,ANESTHESIA:,  General with controlled ventillation.,GROSS FINDINGS: , The patient is a 58-year-old black male with chronic renal failure.  He undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  There is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite, placed in supine position.  General anesthetic was administered.  Left arm was prepped and draped in appropriate manner.  A Pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  Utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  Transverse graftotomy was created.  A #4 Fogarty catheter passed proximally and distally restoring inflow and meager inflow.  A fistulogram was performed and the above findings were noted.  In a retrograde fashion, the proximal anastomosis was patent.  There was no narrowing within the forearm graft.  Both veins were flushed with heparinized saline and controlled with a vascular clamp.  A longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  Utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  The distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 Prolene suture tied upon itself.  The vein was controlled with vascular clamps.  Longitudinal venotomy created along the anteromedial wall.  A 7 mm graft was brought on to the field and this was cut to shape and size.  This was sewed to the graft in an end-to-side fashion with U-clips anchoring the graft at the heel and toe with interrupted #6-0 Prolene sutures.  Good backflow bleeding was confirmed.  The vein flushed with heparinized saline and graft was controlled with vascular clamp.  The end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 Prolene suture.  Good backflow bleeding was confirmed.  The graftotomy was then closed with interrupted #6-0 Prolene suture.  Flow through the fistula was permitted, a good flow passed.  The wound was copiously irrigated with antibiotic solution.  Sponge, needles, instrument counts were correct.  All surgical sites were inspected.  Good hemostasis was noted.  The incision was closed in layers with absorbable sutures.  Sterile dressing was applied.  The patient tolerated the procedure well and returned to the recovery room in apparent stable condition.",Fogarty Thrombectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene"
"Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.","PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.",Craniotomy - Frontotemporal,Neurosurgery,"neurosurgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,"
Initial obstetrical examination - Normal first pregnancy.  Inadequate naternal nutrition.,"CHIEF COMPLAINT,:  This 32 year-old female presents today for an initial obstetrical examination.  Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).  LMP:  02/13/2002 EDD:  11/20/2002 GW:  8.0 weeks.  Patient has been trying to conceive for 6 months.,Menses:  Onset:  12 years old.  Interval:  24-26 days.  Duration:  4-6 days.  Flow:  moderate.  Complications:  PMS - mild.,Last Pap smear taken on 11/2/2001.  Contraception:  Patient is currently using none.,ALLERGIES:,  Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness.  Medication History:  None.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.  Past Surgical History:  Patient admits past surgical history of tonsillectomy in 1980.  Social History:  Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:,  Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding.  Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:,  BP Standing:  126/84 Resp:  22 HR:  78 Temp:  99.1 Height:  5 ft.  6 in.  Weight:  132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 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.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face:  Examination of head and face is unremarkable.,Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  No edema observed.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory:  Lungs CTA.,Breast:  Chest (Breasts):  Breast inspection and palpation shows no abnormal findings.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary:  External genitalia are normal in appearance.  Examination of urethra shows no abnormalities.  Examination of vaginal vault reveals no abnormalities.  Cervix shows no pathology.  Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.  Adnexa and parametria show no masses, tenderness, organomegaly or nodularity.  Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test:  positive. CBC results within normal limits.  Blood type:  O positive.  Rh:  positive.  FBS:  88 mg/dl.,IMPRESSION:,  Pregnancy, normal first.  Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:,  Pap smear submitted for manual screening.  Ordered CBC.  Ordered blood type.  Ordered hemoglobin.  Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:,  Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity.  Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:,  NatalCare Plus Dosage:  Prenatal Multivitamins tablet Sig:  QD Dispense:  60 Refills:  4 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient received written information regarding pre-eclampsia and eclampsia.  Patient was instructed to restrict activity.  Patient instructed to limit caffeine use.  Patient instructed to limit salt intake.",OB/GYN - H&P,Obstetrics / Gynecology,
Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,"EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home.",Carotid & Cerebral Arteriograms,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,"
"Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.","REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",Lung Cancer & MI - Hospice Cosult,Hematology - Oncology,
"Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.","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.",Thoracoscopy & Thoracotomy - Mesothelioma,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy,"
"Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.","INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.",Angiography & Catheterization - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal,"
"Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.","PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.",Nephrology Consultation - 3,Nephrology,"nephrology, kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension"
"GI Consultation due to rectal bleeding, positive celiac sprue panel","PROBLEM:  ,Rectal bleeding, positive celiac sprue panel.,HISTORY:  ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  She actually has none of these symptoms since starting her gluten-free diet.  She has noted intermittent rectal bleeding with constipation, on the toilet tissue.  She feels remarkably better after starting a gluten-free diet.,ALLERGIES: , No known drug allergies.,OPERATIONS: , She is status post a tonsillectomy as well as ear tubes.,ILLNESSES: , Questionable kidney stone.,MEDICATIONS: , None.,HABITS: , No tobacco.  No ethanol.,SOCIAL HISTORY: , She lives by herself.  She currently works in a dental office.,FAMILY HISTORY: , Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  She has two sisters and one brother.  One sister interestingly has inflammatory arthritis.,REVIEW OF SYSTEMS:  ,Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet.  She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  Please see symptoms summary sheet dated April 18, 2005.,PHYSICAL EXAMINATION:  , GENERAL:  She is a well-developed pleasant 19 female.  She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  She has anicteric sclerae.  Pink conjunctivae.  PERRLA.  ENT:  MMM.  NECK:  Supple.  LUNGS: Clear to auscultation.",GI Consultation - 1,Gastroenterology,"gastroenterology, bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet,"
Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed.   A screw had come loose.,"Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated.  On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee.  He is unable to crawl and/or kneel.  He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill.  Stairs are a significant problem.  His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice.  He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS:  ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day.  He denies any alcohol consumption.,PHYSICAL EXAMINATION:  ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds.  He does not appear to be in distress at this time.  One could appreciate 1-2/4 intraarticular effusion.  The range of motion is 0 to a 110 degrees of flexion.  I could not appreciate any evidence of instability medial, lateral, anterior or posterior.  Crepitus is noted with regards to range of motion testing.  His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh.  The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1.  First report of injury.,2.  July 17, 2002, x-rays of the right knee were negative.,3.  Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4.  August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial",Records Review - Orthopedic,Orthopedic,
"Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.","REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.",Peripheral Effusion - Consult,Cardiovascular / Pulmonary,
"D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.6.  Grade 1+ rectocele.","PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.",D&C & Hysteroscopy Followup,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus"
"Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.","CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.",Foreign Body - Right Nose,Pediatrics - Neonatal,
Diagnostic laparoscopy and drainage of cyst.,"PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.",Laparoscopy - Drainage of Cyst,Obstetrics / Gynecology,"obstetrics / gynecology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,"
"A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.","REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",Neuropsychological Evaluation - 2,Psychiatry / Psychology,
This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",Ultrasound OB - 5,Radiology,
"Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.","PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.",CABG - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex,"
A routine return appointment for a 71-year-old woman with chronic atrial fibrillation.  Chief complaint today is shortness of breath.,"REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.",Chronic Atrial Fibrillation,Cardiovascular / Pulmonary,
Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,"PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.",Anterior Cervical Discectomy - 3,Orthopedic,"orthopedic, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,"
"The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.","HISTORY:  ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital.  This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve.  A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve.  The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  The patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was exchanged over wire.  A 5-French marker pigtail catheter was directed into the main pulmonary artery.  A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  The left femoral venous sheath was exchanged over wire for a 7-French sheath.  Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram.  The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:  ,Oxygen consumption was assumed to be in normal.  Mixed venous saturation that was not normal with no evidence of intracardiac shunt.  Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg.  Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg.  Left ventricular systolic pressure was systemic.  No outflow constriction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification.  The proximal narrowing of the distal main pulmonary artery was appreciated.  Neointimal ingrowth within the proximal stents were appreciated.  There is good distal growth of the pulmonary arteries.  Arborization appeared normal.  Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  The main pulmonary pressures remained similar.  There was 10 mmHg systolic gradient into the branch of pulmonary arteries.  There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg.  Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve.  A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  There was no evidence of intimal disruption.,DIAGNOSES: ,1.  Atrioventricular septal defect.,2.  Tetralogy of Fallot with the pulmonary atresia.,3.  Bilateral superior vena cava.  The left cava draining to the coronary sinus.,4.  The right aortic arch.,5.  Discontinuous pulmonary arteries.,6.  Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Repair of tetralogy of Fallot with external conduit.,3.  The atrioventricular septal defect repair.,4.  Unifocalization of branch pulmonary arteries.,5.  Bilateral balloon pulmonary angioplasty and stent implantation.,6.  Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES:  ,1.  Mild-to-moderate proximal branch pulmonary stenosis.,2.  Well-functioning Contegra valve and current intervention.  A balloon dilation of the right pulmonary artery.,3.  Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued.  Further cardiologic care be directed by Dr. X.",Atrioventricular Septal Defect,Cardiovascular / Pulmonary,
"Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.","REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.",Glioma - Consult,Hematology - Oncology,
Sellar HCT - Pituitary mass,"CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.",HCT - Pituitary Mass,Neurology,"neurology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision,"
Left temporal craniotomy and removal of brain tumor.,"PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.",Craniotomy - Temporal,Neurosurgery,"neurosurgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,"
"Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.","REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.",Craniopharyngioma - Postop,Neurology,"neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,"
Patient being referred for evaluation of glaucoma.,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,",Ophthalmology - Letter - 2,Ophthalmology,"ophthalmology, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact,"
"Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.","ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.",Neck Pain - Discharge Summary,Orthopedic,"orthopedic, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,"
"Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.","TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.",Pars Plana Vitrectomy & Lensectomy,Ophthalmology,
"Enlarged fibroid uterus, hypermenorrhea, and secondary anemia.  Dilatation and curettage and hysteroscopy.","PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,3.  Secondary anemia.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm.  The cervix is patulous and nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum.  The uterus was sounded to a depth of 11 cm.  The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar.  The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera.  The endometrial cavity was distended with fluids and the cavity visualized.  Multiple irregular areas of fibroid degeneration were noted throughout the cavity.  The coronal areas were visualized bilaterally with corresponding tubal ostia.  A moderate amount of proliferative appearing endometrium was noted.  There were no direct intraluminal lesions seen.  The patient tolerated the procedure well.  Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis.  The instrument was removed from the vaginal vault.  The patient was sent to recovery area in satisfactory postoperative condition.",D&C & Hysteroscopy,Obstetrics / Gynecology,"obstetrics / gynecology, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus"
"Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.","REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.",Cervical Spondylosis - Neuro Consult,Neurology,"neurology, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord,"
"Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.",Low-Transverse C-Section & BTL - 2,Obstetrics / Gynecology,
Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,"COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:,  The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability.  He is a 43-year-old married, white male who came unaccompanied to the evaluation.  He drove himself suggesting that he drives regularly.  He reportedly has been on Disability since around 2002.  He was a good historian, freely offering information.  He was dressed and groomed casually, yet neat and appropriate in appearance.  He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning.  No censorship of data was indicated.  ,PRESENT PROBLEMS:,  The claimant described his recent problems as, ""serious depression.  Very hard to concentrate.  Very short tempered.  Usually distracted."" ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago.  He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because ""I had a breakdown and ended up in the hospital.  They said that I wasn't reliable enough and laid me off.""  Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed.  ,The claimant has had significant emotional problems since around 1997.  He was first hospitalized in that year and has been hospitalized five more times since then.  The last hospitalization was last month in Atlanta, Georgia.  He has tried to overdose in the past as well as cut his wrist.  He even had to undergo electroconvulsive therapy in 2001, because of depression.  He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident.  Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d.  He is not involved in outpatient therapy.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  The claimant indicated that he graduated from high school in regular classes.  He did have to repeat the kindergarten because he was too young.  He worked for about 10 years at a company in Massachusetts.  He was not advancing on that job and therefore quit.  He has had three subsequent jobs and a number of emotional problems since.  He indicated usually getting along with others but stated, ""I had trouble taking direction from someone younger than me.  I resent getting nagged at.  I'd get angry or just seethe.""  He has been let go from his last two jobs because of emotional issues.  ,The claimant was married the first time for five years.  He has no children.  He now lives at home with his wife., ,The claimant denied any legal problems.  He suggested that his mother had bipolar disorder.  He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs.  He stopped drinking in 1997.  Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:,  The claimant described his typical day as follows, ""I usually get up about 7:00 to 7:30.  Have breakfast.  Take a shower about 8:30.  Do errands.  Me and my wife are out of the house by 9:00.  Check e-mail at the library.  I like the computer.  We have lunch 11:30 or 12:00.  Do errands or watch talk shows or I'll read.  I love to read.  Around 5:00 to 5:30, have supper.  Watch the news, game shows.  In bed by 10:00.""  He will help with vacuuming, doing the dishes or yard work.  His wife does most of the house cleaning.  He does no cooking.  He and his wife get out every day usually for three or four hours.  He has a neighbor next door that he will see twice a week.  He used to go to the gym but has not been in a few weeks.  No other family contact was described and he does not go to church.  When asked what he enjoys he stated, ""read, use my computer or go ride my bike."", ,MENTAL STATUS EVALUATION:,  On interview, the claimant looked his stated age of 43 years.  He was tall in stature and thin in weight.  He was neat and clean in appearance.  Posture was somewhat tense but psychomotor activity was not remarkable.  Eye contact was fleeting with fair social skills evident.  Facial expression was tense and affect was restricted with little animation noted.  General mood appeared dysphoric.  Speech was clear, coherent, logical, goal-directed and relevant.  He was cooperative in attitude toward the examiner.  He described his recent mood as, ""cloudy, gray because we've got a lot of personal problems right now.  I'm frustrated because I don't know where things are going.""  He described some problems with falling asleep and staying asleep at night as well as decreased energy level.  He denied appetite disturbance.  He has lost interest in some activities suggesting mild anhedonia.  He has trouble with attention and concentration stating, ""I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder.""  He has thoughts of suicide about once or twice a week and has often fled situations in the past.  He stated, ""I try to keep myself from running away.""  He denied any plan or intent for suicide.  He suggested significant anxiety problems as well.  He stated, ""I'm dealing with pedophilia.  I try to time it so that I don't go to a store with lots of people around.  If there is people I get real edgy, heart pounds, shortness of breath.  A lot of chest discomfort.""  He has these panic symptoms quite regularly and they have occurred ever since 1997.  That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail.  No phobic processes were suggested.  No psychotic symptoms were revealed.  He denied hallucinations and no delusional material was elicited.  Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres.  He evidenced adequate memory for both recent and remote events.  He was able to recall 3 of 3 words after a 1 minute and 10 minute delay.  Fair sustained attention and concentration skills were shown.  He was able to spell a word backward and performed a serial 7 subtraction task affectively.  Basic calculation skills were intact and no language-based dysfunction was noted.  Social judgment was also intact as he gave a good response to finding a wallet in the street, ""find who the owner was, bring it to the police station or contact the person,"" and to seeing smoke in a theater, ""Get a hold of staff so they could evacuate.""  Adequate conceptual abilities was shown with similarity comparisons.  Somewhat limited abstraction was shown with proverb interpretation, glass houses, ""don't do anything you're not supposed to do.""  Premorbid intellect is estimated to be at least in the average range.  Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I:  Major Depression, recurrent, moderate.  Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:,  Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities.  He continues to show significant problems with depression and anxiety.  He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations.  He relies on his wife to take care of most all household task.  He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:,  The claimant was strongly encouraged to get some additional help for his emotional problems.  He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.",Mental Status Evaluation,Psychiatry / Psychology,
"Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.  Comminuted fracture, dislocation left proximal humerus.","PREOPERATIVE DIAGNOSIS:,  Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic.  He was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus.  The left shoulder and upper extremities were then prepped and draped in the usual manner.  A longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus.  This incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery.  Hemostasis was achieved with the cautery.  The deltoid fascia were identified, skin flaps were then created.  The deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein.  The deltoid was then retracted.  There was marked hematoma and swelling within the subdeltoid bursa.  This area was removed with rongeurs.  The biceps tendon was identified which was the landmark for the rotator interval.  Mayo scissors was utilized to split the remaining portion of the rotator interval.  The greater tuberosity portion with the rotator cuff was identified.  Excess bone was removed from the greater tuberosity side to allow for closure later.  The lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,Excess bone was removed from the lesser tuberosity as well.  Both of these were tagged with Ethibond sutures for later.  The humeral head was delivered out of the wound.  It was localized to the area of the anteroinferior glenoid region.  The glenoid was then inspected, and noted to be intact.  The fracture was at the level of the surgical neck on the proximal humerus.  The canal was repaired with the broaches.  An #8 stem was chosen as it was going to be cemented into place.  The trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion.  Trial reduction was performed.  The 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder.  At this point, the wound was copiously irrigated with gentamycin solution.  The canal was copiously irrigated as well and suctioned dry.  Methyl methacrylate cement was mixed.  The cement gun was filled and the canal was filled with the cement.  The #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured.  Excess cement was removed by sharp dissection.  Prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later.  Once the cement was cured, the modular head was impacted on to the Morse taper.  It was stable and the shoulder was reduced.  The lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant.  The greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well.  The rotator interval was closed with #2 fiber wire in an interrupted fashion.  The biceps tendon was ________ within this closure.  The wound was copiously irrigated with gentamycin solution, suctioned dry.  The deltoid fascia was then approximated with interrupted #2-0 Vicryl suture.  Subcutaneous layer was approximated with interrupted #2-0 Vicryl and skin approximated with staples.  Subcutaneous tissues were infiltrated with 0.25% Marcaine solution.  A bulky dressing was applied to the wound followed by application of a large arm sling.  Circulatory status was intact in the extremity at the completion of the case.  The patient was then transferred to recovery room in apparent satisfactory condition.",Hemiarthroplasty - Shoulder,Orthopedic,"orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,"
A 21-year-old female was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.,"PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.",Vacuum D&C,Obstetrics / Gynecology,"obstetrics / gynecology, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,"
CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.",CT C-Spine - 2,Neurology,"neurology, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE"
"Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.","PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.",Osteotomy & Bunionectomy,Orthopedic,
"Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.","PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.",Anterior Cervical Discectomy & Fusion - 2,Neurosurgery,"neurosurgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior"
Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.,"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Cholangiocarcinoma Consult,Gastroenterology,
"Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy.  Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.","PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003.  The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass.  The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in normal sterile fashion.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline.  The fascial incision was then extended laterally with Mayo scissors.  The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder.  The uterus and left adnexa were then palpated and brought out into the surgical field.  The fundus of the uterus was grasped with a Lahey clamp.  The GYN/Balfour retractor was placed.  The bladder blade was placed.  The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed.  At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass.  Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat.  It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides.  Next, the right ________ was isolated bluntly as the patient had a previous RSO.  This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch.  Attention was then turned to the left round ligament, which was tented up with the Babcock.  Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums.  The left infundibulopelvic ligament was then bluntly isolated.  It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch.  The bladder flap was then placed on tension with Allis clamps.  It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians.  It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec.  The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture.  The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps.  These were then transected and suture ligated with #0 Vicryl suture.  The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible.  It was then entered with the last transection.  The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors.  The angles of the vaginal cuff were then grasped with Kocher clamps.  A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed.  Good hemostasis was appreciated.  A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl.  This was tagged for later use.  The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture.  The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place.  The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated.  The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion.  The GYN/Balfour retractor and bladder blade were then removed.  The bowel was then packed.  Again copious suction irrigation was performed with hemostasis appreciated.  The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion.  The fascia was then reapproximated with #0 Vicryl suture in a running fashion.  The Scarpa's  fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion.  Steri-Strips were placed.  At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally.  The patient tolerated the procedure well and was taken to Recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  Specimens include uterus, cervix, left fallopian tube, and ovary.",TAH & Salpingo-oophorectomy,Obstetrics / Gynecology,
Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,"NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.",Nuclear Cardiac Stress Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina,"
"Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.","PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.",Cardiac Catheterization - 6,Cardiovascular / Pulmonary,
A 75-year-old female comes in with concerns of having a stroke.,"SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.",Bell's Palsy,Neurology,"neurology, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s"
Patient with a history of ischemic cardiac disease and hypercholesterolemia.,"HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.",Ischemic Cardiac Disease - Progress Note,Cardiovascular / Pulmonary,
Axial images through the cervical spine with coronal and sagittal reconstructions.,"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.",CT C-Spine - 1,Neurology,"neurology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct,"
Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",Thyroid Mass Consult,Pediatrics - Neonatal,
Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,"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 - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate,"
"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.","REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 3,Psychiatry / Psychology,
A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.,"As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk.  She had HMO insurance at that time and saw a neurologist, whose name she does not recall.  She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests.  She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved.  She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia.  She saw a urologist and underwent urodynamic testing.  She was diagnosed as having ""overactive bladder"", but the cause of this was never determined.  She was treated with medications, possibly Ditropan, without much benefit.  She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable ""stiffness"" in her feet and slight swelling of the ankles.  Apparently, the swelling was not visible by others.  She saw multiple physicians and was told that it was ""not arthritis"", but no definite diagnosis was ever established.  She saw at least two rheumatologists on several occasions and blood tests were all normal.  No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat.  She states from time-to-time she could ""barely walk"".  She felt as if her balance is impaired and she felt as if she were ""walking on stilts"".  She tried arch supports from a podiatrist without any benefit.  She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X.  He ordered an MRI scan of her brain and lumbar spine.  He also did some sort of nerve testing and possibly visual evoked response testing.  After reviewing everything, he diagnosed multiple sclerosis.  However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003.  Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex.  She continued on it for about six months.  However, it made her feel much more stiff and delayed and so she finally stopped it.  She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy.  So, she discontinued it also.,At that point in time, she decided to try a program of ""good nutrition, vitamin supplements, and fish oil"".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities.  She began to have to use a cane.  She was seen in neurological consultation by Dr. Z.  She was treated with a Medrol Dosepak.  Her spasticity and swelling seemed to improve dramatically.  However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005).  This seemed to be less helpful than the oral steroids, but was partially beneficial.  However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to ""look better"".  She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets.  She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs.  She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability.  There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:,  The patient is allergic to LOBSTER and VICODIN.  She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:,  She does not smoke.  She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries.  Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:,  The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet.  There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum.  There appear to be Dawson's fingers.  The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05.  The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal.  Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord.  It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General:  Well-developed, well-nourished female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  Awake, alert, oriented to time, place, and person; appropriate.  Recent and remote memory intact.  No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II:  Visual fields full to confrontation.  Fundi benign.,III, IV, VI:  Extraocular movements full throughout, without nystagmus.  No ptosis.  Pupils equal, round and react briskly to light and accommodation.,V:  Normal sensation to light touch and pinprick bilaterally.  Corneal reflexes equal bilaterally.  Motor function normal.,VII:  No facial asymmetry.,VIII:  Hears finger rub bilaterally.  Weber and Rinne tests normal.,IX & X:  Palate elevates symmetrically bilaterally with phonation.  Gag reflex equal bilaterally.,XI:  Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII:  Tongue midline without atrophy or fasciculations.  Rapid alternating movements normal.  No dysarthria.,Motor:  Tone, bulk, and strength are normal in both upper extremities.  In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left.  There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left):  Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5.  There are no tremors, fasciculations or abnormal involuntary movements.",Comprehensive Neurological Evaluation,Neurology,
Common CT C-Spine template,"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.",CT C-Spine,Orthopedic,"orthopedic, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE"
CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.,"EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.",CT of Chest with Contrast,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest"
"Right and left heart catheterization, coronary angiography, left ventriculography.","PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,",Heart Catheterization,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions"
"Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.","REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.",Peripheral Effusion - Consult,Cardiovascular / Pulmonary,
Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,"HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.",Abnormal Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress"
Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.,"COMPREHENSIVE CLINICAL PSYCHOLOGICAL EVALUATION,CURRENT MEDICATIONS:,  Nexium 4 mg 4 times per day, Propanolol 10 mg 4 times a day, Spironolactone 100 mg 3 times per day, Lactulose 60 cc's 3 times a day.,GENERAL OBSERVATIONS:  ,Mr. Abc, a 54-year-old black married male who was referred for a Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.  Mr. Abc arrived five minutes late for his scheduled appointment.  He was accompanied to the office by his sister-in-law who drove him to the appt.  Mr. Abc currently does not receive Disability benefits.  This is the first time he has filed for Disability.  The Authorization form listed Mr. Abc's current complaints as ""cirrhosis of the liver and mental issues.""  Mr. Abc was well groomed and wore casual attire.  He looked older than his stated age.  The whites of his eyes were very jaundiced.  His posture was slightly stooped and his gait was slow.  He was winded after walking up the stairs.  Psychomotor activity was retarded.  Mr. Abc was cooperative throughout the interview.  Although he appeared to be answering most questions to the best of his ability, he appeared to be minimizing his emotional distress.  ,PRESENT ILLNESS: , Most information was provided by Mr. Abc who appeared to be a fairly reliable source.  His information was supplemented by review of his medical records.  Mr. Abc has applied for Federal Disability benefits believing that he qualifies based on his cirrhosis of the liver and his cognitive dysfunction.  Mr. Abc was diagnosed with cirrhosis in 1991.  His condition has worsened to the point that he is experiencing liver failure and is awaiting a liver transplant.  He stated that his main symptom is extreme fatigue.  He has no energy and is unable to engage in many activities.  Over the past year he was admitted to the hospital four times for confusion and bizarre behavior.  He stated that his sister-in-law and his wife told him that he had become violent and he fought with the Sherriff who was trying to take him to the hospital.  He has no memory of this.  Mr. Abc stated that he was hospitalized one time.  Actually he had begun having problems with confusion in July of 2004 and he has been treated four times since that time.  According to his medical records, he was found wandering outside of his home.  He was apparently delusional believing that a tree branch was a doorknob.  Mr. Abc also suffers from edema and swelling in his legs and his feet.  Mr. Abc attempted to return to work and found that he was unable to do his job due to the necessity of walking one-quarter mile from the front to the back of the plant.  He was unable to walk very far without becoming fatigued.  He had instances where he had passed out after becoming faint.  He had trouble at work sitting for very long because his feet swelled.  He was unable to lift the required 10 pounds of medication boxes.  When he found himself unable to do his regular job, he tried another job at the same plant but was unable to do that job.  He also became confused easily at work.  His doctor advised him to quit and then he did so in March of this year.  In addition to his cognitive symptoms, Mr. Abc has had some disturbance in mood as well.  He related that he feels very sad since he lost his job.  A lot of his self-esteem came from working.  He worries about financial problems.  His sleep has been disturbed.  He sleeps four to five hours a night with trouble falling asleep and frequent awakening in the middle of the night.  His appetite is fair.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  Mr. Abc completed the 11th grade. He went on to get his GED in 1971.  He stated that he has never failed a grade and he has no history of a learning disability.  He received no special education services.  His grades were Bs and Cs. He stated that he was suspended from school one time for fighting but got along well in general. Mr. Abc is currently unemployed.  His last job was at Baxter Health Care where he worked for four years.  It was his longest place of employment.  He quit in March of 2005 because of fatigue and inability to perform the necessary job duties.  He denies that he was ever fired from a job and he reported good work relationships.  Mr. Abc has been married for two years. He has no prior marriages.  He has one daughter age 13.  He currently lives with his wife. Has been at his current address for four years.  ,HISTORY OF OTHER PERTINENT MEDICAL EVENTS: , Mr. Abc has cirrhosis of the liver, hepatitis C, hepatic encephalopathy, and gastroesophageal reflux disease, and hypertension. Surgeries include a cardiac catheterization in 2001, a liver biopsy in 2003.  Over the past year he has been hospitalized four times due to confusion and bizarre behaviors stemming from his liver failure.  ,DAILY ACTIVITIES AND FUNCTIONING:  ,Mr. Abc stated that he tries to do things but he has been severely restricted due to his extreme fatigue.  He enjoys reading and does it regularly.  He tries to help his wife with the household chores as he can.  He has washed dishes, cooked, mopped, dusted, vacuumed and has done laundry occasionally over the past month but not as much as he used to.  He stated that he used to mow the yard and do yard work but he can no longer do it because of his extreme fatigue.  He has given up driving all together and he no longer goes out alone.  He spends most days at home.  He enjoys going to church and he prays daily.  ,MENTAL HEALTH HISTORY: , Mr. Abc has never been diagnosed or treated for a mental health disorder.  He denied any history of mental health problems in his family.  He stated that he was evaluated one time earlier this year by a psychiatrist to determine his suitability for a liver transplant.  He was approved and he is now on the waiting list to receive a liver.  ,SUBSTANCE USE HISTORY:  ,Mr. Abc has a history of substance use beginning in his teenage years.  He has used alcohol, marijuana and cocaine.  He stated that he only used the marijuana and cocaine a few times when he was young but he continued using alcohol until recently.  His alcohol use became problematic and he was arrested for DWI three times.  He attended AA and the DART program.  Mr. Abc stated that he has been clean for eight years and five months.",Psychological Evaluation,Psychiatry / Psychology,
"C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.","PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.",Anterior Cervical Discectomy & Fusion - 8,Orthopedic,"orthopedic, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft"
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",Hypergranulation - Consult,Orthopedic,
"This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.","CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",Huntington's Disease - Consult,Neurology,
"Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.","PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.",Neck Mass Biopsy,Hematology - Oncology,"hematology - oncology, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,"
"Postoperative wound infection, complicated.  Irrigation and debridement of postoperative wound infection.  Removal of foreign body.  Placement of vacuum-assisted closure.device.","TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.",I&D - ORIF Wound,Orthopedic,"orthopedic, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,"
Central line insertion.  Empyema thoracis and need for intravenous antibiotics.,"PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.",Central Line Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter,"
Patient with episode of lightheadedness and suddenly experienced vertigo.,"CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The ""vascular blush"" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.",Dural AVM,Neurology,"neurology, avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar,"
Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.,"CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110.  HR 85.  RR 16.  Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.",Cerebral Angiogram - Lateral Medullary Syndrome,Neurology,"neurology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral,"
Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.,"DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.",Delivery Note - 3,Obstetrics / Gynecology,"obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Esophagogastroduodenoscopy with biopsies.  Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.","PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.",Esophagogastroduodenoscopy with Biopsies,Gastroenterology,"gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,"
MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",MRI T-Spine - Spinal Mets,Orthopedic,
Colonoscopy due to hematochezia and personal history of colonic polyps.,"PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.",Colonoscopy - 6,Gastroenterology,
"The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.","REASON FOR VISIT:  ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.,MAJOR FINDINGS:,  On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  She is well developed, well nourished, and kempt.,Vital Signs:  Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves:  Intact for extraocular movements.  Facial movement, hearing, head turning, tongue, and palate movements are all intact.  I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact.  She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  It looks like there is a little bit of dry blood there.,ASSESSMENT:,  The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1.  Pseudotumor cerebri without papilledema.,2.  Migraine headaches.,PROCEDURES:,  I programmed her shunt to 90 mmH2O.,PLAN:,  It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray.  However, the picture of the x-ray was not the most desirable picture.  Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90.  In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment.  She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.",Pseudotumor Cerebri,Neurology,"neurology, migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema"
"Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.","CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,",Heart Catheterization & Angiography - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,"
"Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.","DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,",Bronchiolitis - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs,"
"Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.","PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.",Phacoemulsification of Cataract,Ophthalmology,"ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,"
"Synovitis - anterior cruciate ligament tear of the left knee.  The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.   The patient fell in a grocery store.  He reports slipping on a grape that was on the floor.","DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.",Physical Therapy - Synovitis,Orthopedic,
Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,"PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia.  The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME:  ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:,  None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL:  ,The patient is a 5-year-4-month-old male who presents for evaluation of feet.  He has been having significant feet pain with significant planovalgus deformity.  The patient was noted to have flexible vertical talus.  It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening.  This was explained to the mother in detail.  This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time.  All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered.  The patient received Ancef preoperatively.  Bilateral nonsterile tourniquets were placed on each thigh.  A bump was placed underneath the left buttock.  Both the extremities were then prepped and draped in standard surgical fashion.  Attention was first turned towards the left side.  Intended incision was marked on the skin.  The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view.  The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg.  Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint.  The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally.  Once the foot was reduced a Steinman pin was used to hold it in position.  This position was first checked on the fluoroscopy.  The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction.  This was also checked with fluoroscopy.  The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half.  This was sutured using 2-0 Ethibond and that was also oversewn.  The wound was irrigated with normal saline.  The periosteal flap was sutured over the staple using 2-0 Vicryl.  Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl.  The area was injected with 6 mL of 0.25% Marcaine local anesthetic.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril.  Tourniquet was released after 53 minutes.  The exact same procedure was repeated on the right side with no changes or complications.  Tourniquet time on the right side was 45 minutes.  The patient tolerated the procedure well.  Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch.  The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request.  The patient is to be strict nonweightbearing for at least 6 weeks.  He is to follow up in the next 10 days for a check.  We will plan of changing to short-leg casts in about 4 weeks postop.",Arthrodesis,Orthopedic,"orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral,"
"Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.","ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.",CVA Consult - ER Visit,Neurology,
Left and right coronary system cineangiography.  Left ventriculogram.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.",Cineangiography - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis,"
Pulmonary function test.  Mild restrictive airflow limitation.  Clinical correlation is recommended.,"OBSERVATIONS: , FEV1 is 3.76, 103% predicted.  FVC is 4.98, 110% predicted.  Ratio is 75.  FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%.  DLCO is 35, 121% predicted.  Residual volume is 3.04, 139% predicted.  Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:,  Mild restrictive airflow limitation.  Clinical correlation is recommended.",Pulmonary Function Test - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.","REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.",Coronary Angiography,Cardiovascular / Pulmonary,
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.,"PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.",Chest Tube Insertion in ER,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,"
The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.,"PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:,  Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  A Gore exclusive device was used 3 pieces were used to effect the repair.  We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  The right hypogastric artery had been previously coiled off.  Left common femoral artery was used for the _____ side.  We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side.  The calibrated aortogram was the done.  We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately.  A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  The area was ballooned aggressively.  It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas.  Both femoral arteries were repaired by primary suture technique.  Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly.  Meticulous hemostasis was achieved.  Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied.  Sponge and needle counts were reported as correct.  The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.",Endovascular Abdominal Aortic Aneurysm Repair,Gastroenterology,"gastroenterology, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,"
"A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.","HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",Cardiac Consultation,Cardiovascular / Pulmonary,
"Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.","PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.",Port-A-Cath Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire,"
She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation.,"DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.",Delivery Note - 9,Obstetrics / Gynecology,"obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
CT brain (post craniectomy) - RMCA stroke and SBE.,"CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres.",CT Brain,Neurology,"neurology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness,"
"Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.","REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.",Echocardiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral,"
"MRI of the Cervical, Thoracic, and Lumbar Spine","INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,",MRI Spine,Orthopedic,"orthopedic, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.",Pulmonary Medicine Clinic Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary,"
1-month-old for a healthy checkup - Well child check,"SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.",Well-Child Check - 8,Pediatrics - Neonatal,
"Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.","PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,",Gastrostomy,Gastroenterology,"gastroenterology, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy"
2-D Echocardiogram,"1.  The left ventricular cavity size and wall thickness appear normal.  The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  There is near-cavity obliteration seen.  There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2.  The left atrium appears mildly dilated.,3.  The right atrium and right ventricle appear normal.,4.  The aortic root appears normal.,5.  The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  Estimated pulmonary artery systolic pressure is 49 mmHg.  Estimated right atrial pressure of 10 mmHg.,8.  The pulmonary valve appears normal with trace pulmonary insufficiency.,9.  There is no pericardial effusion or intracardiac mass seen.,10.  There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,",2-D Echocardiogram - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery"
"Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.","INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.",Cardiac Catheterization - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery"
Patient referred for evaluation of her left temporal lobe epilepsy.,"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,",Consult - Seizures,Neurology,
"Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.","PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.",Wrist Ganglion Excision,Orthopedic,"orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion"
2-D Echocardiogram,"1.  The left ventricular cavity size and wall thickness appear normal.  The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  There is near-cavity obliteration seen.  There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2.  The left atrium appears mildly dilated.,3.  The right atrium and right ventricle appear normal.,4.  The aortic root appears normal.,5.  The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  Estimated pulmonary artery systolic pressure is 49 mmHg.  Estimated right atrial pressure of 10 mmHg.,8.  The pulmonary valve appears normal with trace pulmonary insufficiency.,9.  There is no pericardial effusion or intracardiac mass seen.,10.  There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,",2-D Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery"
"Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.","PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.",ORIF & Cervical Fusion,Orthopedic,"orthopedic, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation,"
Endoscopic release of left transverse carpal ligament.,"PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",Carpal Ligament Release - 1,Orthopedic,"orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic,"
MRI C-spine: C4-5 Transverse Myelitis.,"CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly ""normal."",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.",MRI C-spine,Orthopedic,"orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf,"
Patient complains of chest pain - possible esophageal reflux,"CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.",ER Report - Chest Pain,Cardiovascular / Pulmonary,
Cardiology office visit sample note.,"HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.",Cardiology Office Visit - 3,Cardiovascular / Pulmonary,
Ruptured appendicitis.,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.",Laparoscopic Appendectomy - 1,Gastroenterology,"gastroenterology, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy,"
Left third digit numbness and wrist pain.,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",MRI C3 - Cord Compression.,Orthopedic,
MRI Brain - Olfactory groove meningioma.,"CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.",MRI Brain -  Meningioma (Olfactory),Neurology,"neurology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual,"
Holter monitor report.   Predominant rhythm is sinus.  Triplet maximum rate of 178 beats per minute noted.,"INDICATIONS: , Predominant rhythm is sinus.  Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute.  Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted.  Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,Triplet maximum rate of 178 beats per minute noted.",Holter Monitor Report - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
A 27-year-old female with a size and date discrepancy.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:",Ultrasound OB - 7,Obstetrics / Gynecology,
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",Metastatic Ovarian Cancer - Consult,Obstetrics / Gynecology,
Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,"PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.",Ventriculostomy Placement,Neurosurgery,"neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular"
Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,"PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.",Craniotomy - Burr Hole,Neurosurgery,"neurosurgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space"
"A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.","CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",Infantile Spasms,Pediatrics - Neonatal,
Excision of left breast mass.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.,"PREOPERATIVE DIAGNOSIS: , Breast mass, left.,POSTOPERATIVE DIAGNOSIS:,  Breast mass, left.,PROCEDURE:,  Excision of left breast mass.,OPERATION: , After obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  The time-out process was followed.  Preoperative antibiotic was given.  The patient was prepped and draped in the usual fashion.  The mass was identified adjacent to the left nipple.  It was freely mobile and it did not seem to hold the skin.  An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  The whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  Hemostasis was achieved with the cautery.  The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl.  A small pressure dressing was applied.,Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.",Breast Mass Excision - 2,Obstetrics / Gynecology,"obstetrics / gynecology, breast mass excision, freely mobile, breast mass, endotracheal, fascia, specimen,"
1-month-old for a healthy checkup - Well child check,"SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.",Well-Child Check - 7,Pediatrics - Neonatal,
"Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.","CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.",Blood per Rectum,Gastroenterology,
"Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.","EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.",CT Lumbar Spine,Orthopedic,"orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis,"
Stress test with Bruce protocol due to chest pain.,"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.,",Stress Test Bruce Protocol,Radiology,
Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.",Pituitary Adenomectomy,Neurosurgery,
Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,"PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.",Cardiac Catheterization - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization,"
"Lightheaded, dizziness, and palpitation.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.","REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.  The patient had some cardiac workup in the past, results are as mentioned below.  Denies any specific chest pain.  Activities fairly stable.  She is actively employed.  No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol normal.  No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:,  SULFA.,PERSONAL HISTORY: , She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past.  Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  An echocardiogram at that time was also normal.  At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No carotid bruits.  No thyromegaly.  No lympyhadenopathy.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI normal.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:,  H&H stable.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.  Chest x-ray unremarkable.,IMPRESSION:,1.  Lightheaded, dizziness in a 50-year-old female.  No documented arrhythmia with the symptoms of palpitation.,2.  Normal cardiac structure by echocardiogram a year and half ago.,3.  Normal cardiac catheterization in 11/07.,4.  Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.",Lightheaded & Dizziness,Cardiovascular / Pulmonary,
"Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.","PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.",Anterior Lumbar Fusion,Neurosurgery,"neurosurgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,"
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,"CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.",Hypergranulation - Consult,Orthopedic,
Psychosocial Evaluation of patient before kidney transplant.,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",Psychosocial Eval for Kidney Transplant,Psychiatry / Psychology,
Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,"POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.",Adenotonsillectomy - 2,ENT - Otolaryngology,"ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.","EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.",Radiologic Exam - Spine,Orthopedic,"orthopedic, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral"
Multiple stent placements with Impella circulatory assist device.,"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.",Multiple Stent Placements,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,"
Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,"PREOPERATIVE DIAGNOSIS:  ,Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,POSTOPERATIVE DIAGNOSIS: , Status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,OPERATION: , Right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,ANESTHESIA: , Endotracheal.,ESTIMATED BLOOD LOSS: , 250 mL,REPLACEMENTS:  ,3 units of packed cells.,DRAINS:,  None.,COMPLICATIONS: , None.,PROCEDURE:  ,With the patient prepped and draped in the routine fashion in the supine position with the head in a Mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  Additional aspect of the temporalis muscle and fascia were incised with cutting Bovie current with effort made to preserve the posterior limb of the external carotid artery.  The scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and Allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and Allis clamps.  The bone flap, which had not been fixed in place was removed.  An additional portion of the temporofrontal bone based at the zygoma was removed with a B1 dissecting tool, B1 attached to the Midas Rex instrumentation.  Further bone removal was accomplished with Leksell rongeur, and hemostasis controlled with the use of bone wax.,At this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  It should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  The sylvian fissure was then dissected with the dissection description being dictated by Dr. X.,Following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on CT angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  This was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,Dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  Until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,Attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by Dr. X. With removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  Self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  Following removal of additional hematoma, the bed of the hematoma site was lined with Surgicel.  Irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,The cortical surface was then covered with Surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a DuraGuard.  The 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,With this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  The wound was then closed.  It should be noted that a pledget of Gelfoam had been placed over the entire dural complex prior to returning the bone flap.  The wound was then closed by approximating the temporalis muscle with 2-0 Vicryl suture, the fascia was closed with 2-0 Vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.",Pterional Craniotomy,Neurosurgery,"neurosurgery, hemorrhage, arteriovenous malformation, aneurysm, pterional craniotomy, bone flap, bipolar coagulation, arteriovenous, pterional, malformation, hematoma, intracerebral,"
"Austin-Moore bipolar hemiarthroplasty, left hip.  Subcapital left hip fracture.","PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA:  ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,HISTORY:  ,The patient is an 86-year-old female who was seen and evaluated in ABCD General Hospital Emergency Department on 08/30/03 after sustaining a fall at her friend's house.  The patient states that she was knocked over by her friend's dog.  She sustained a subcapital left hip fracture.  Prior to admission, she lived alone in Terrano, was ambulating with a walker.  All risks, benefits, and potential complications of the procedure were then discussed with the patient and informed consent was obtained.,HARDWARE SPECIFICATIONS: , A 28 mm medium head was used, a small cemented femoral stem was used, and a 28 x 46 cup was used.,PROCEDURE:  ,All risks, benefits, and potential complications of the procedure were discussed with the patient, informed consent was obtained.  She was then transferred from the preoperative care unit to operating suite #1.  Department of Anesthesia administered spinal anesthetic without complications.,After this, the patient was transferred to the operating table and positioned.  All bony prominences were well padded.  She was positioned on a beanbag in the right lateral decubitus position with the left hip facing upwards.  The left lower extremity was then sterilely prepped and draped in the normal fashion.  A skin maker was then used to mark all bony prominences.  Skin incision was then carried out extending from the greater trochanter in a curvilinear fashion posteriorly across the buttocks.  A #10 blade Bard-Parker scalpel was used to incise the skin through to the subcutaneous tissues.  A second #10 blade was then used to incise through the subcutaneous tissue down to the fascia lata.  This was then incised utilizing Metzenbaum scissors.  This was taken down to the bursa, which was removed utilizing a rongeur.  Utilizing a periosteal elevator as well as the sponge, the fat was then freed from the short external rotators of the left hip after these were placed and stretched.  The sciatic nerve was then visualized and retracted utilizing a Richardson retractor.  Bovie was used to remove the short external rotators from the greater trochanter, which revealed the joint capsule.  The capsule was cleared and incised utilizing a T-shape incision.  A fracture hematoma was noted upon entering the joint capsule as well as subcapital hip fracture.  A cork screw was then used to remove the fractured femoral head, which was given to the scrub tech which was sized on the back table.  All bony remnants were then removed from the acetabulum and surrounding soft tissue with a rongeur.  Acetabulum was then inspected and found to be clear.  Attention was then turned to the proximal femur where a cutting tunnel was used to mark the femur for the femoral neck cut.  An oscillating saw was then used to make the femoral cut.  Box osteotome was then used to remove the bone from proximal femur.  A Charnley awl was then used to open the femoral canal, paying close attention to keep the awl in the lateral position.  Next, attention was turned to broaching.  Initially, a small broach was placed, first making efforts to lateralize the broach then the femoral canal.  It was felt that the patient has less benefit from a cemented prosthesis and a small size was appropriate.  Next, the trial components were inserted consisting of the above-mentioned component sizes.  The hip was taken through range of motion and tested to adduction, internal and external rotations as well as with a shuck and a posterior directed force on a flexed tip.  It was noted that these size were stable through the range of motion.  Next, the trial components were removed and the femoral canal was copiously irrigated and suctioned dried utilizing Super sucker and __________ then inserted pressuring the femoral canal.  The femoral component was then inserted and then held under pressure.  Extruding cement was removed from the proximal femur.  After the cement had fully hardened and dried, the head and cup were applied.  The hip was subsequently reduced and taken again through range of motion, which was felt to be stable.,Next, the capsule was closed utilizing #1 Ethibond in figure-of-eight fashion.  Next, the fascia lata was repaired utilizing a figure-of-eight Ethibond sutures.  The most proximal region at the musculotendinous junction was repaired utilizing a running #1 Vicryl suture.  The wound was then copiously irrigated again to suction dry.  Next, the subcutaneous tissues were reapproximated using #2-0 Vicryl simple interrupted sutures.  The skin was then reapproximated utilizing skin clips.  Sterile dressing was applied consisting of Adaptic, 4x4s, ABDs as well as foam tape.  The patient was then transferred from the operating table to the gurney.  Leg lengths were checked, which were noted to be equal and abduction pillow was placed.  The patient was then transferred to the Postoperative Care Unit in stable condition.",Hemiarthroplasty - Austin-Moore Bipolar,Orthopedic,"orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,"
"Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads.  Open calcaneus fracture on the right.","PREOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,PROCEDURES:,  ,1.  Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2.  Placement of antibiotic-impregnated beads.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS:,  Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:,  After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion.  The tourniquet was inflated and the previous wound was opened.  Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound.  The wound margins were healthy with the exception of very central triangular incision area.  The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension.  The soft dressing was placed.  An Ace was placed.  She was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.",Antibiotic-Impregnated Beads Placement,Orthopedic,"orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic"
"Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.","PREOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, posterior horn of left knee.,2.  Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1.  Carpal tunnel syndrome, right hand, severe.,2.  Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3.  Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1.  Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  Right carpal tunnel release.,3.  Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS:  ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  He failed nonoperative management.  We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table.  After adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  All bony prominences were padded.  The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  Subacromial space was entered.  Visualization was poor due to the hemorrhagic bursitis, and this was resected back.  It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  Rotator cuff was little bit fray, but otherwise intact.  Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  The burr was then introduced to the anterior portal and the distal clavicle excision carried out.  The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well.  The shoulder was then copiously irrigated, drained free of any residual debris.  The wound was closed with 3-0 Prolene.  Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes.  Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis.  The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down.  The patient tolerated this portion of the procedure very well.  The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  These were resected back to the stable surface using a basket forceps and full-radius shaver.  There was no evidence of any other significant arthritis in the knee.  There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.",Arthroscopy Shoulder/Knee,Orthopedic,
Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion.,"PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.",Chest Tube Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma"
"Left thoracotomy with total pulmonary decortication and parietal pleurectomy.  Empyema of the chest, left.","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.",Thoracotomy & Pleurectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest"
"The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.","SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.",SOAP - Shortness of Breath,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,"
"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.","ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.",Goldenhar Syndrome - Discharge Summary,Pediatrics - Neonatal,
Duplex ultrasound of legs,"DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.",Duplex Ultrasound - Legs,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,"
"Spontaneous vaginal delivery.   Term pregnancy at 40 and 3/7th weeks.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.","PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.",Spontaneous Vaginal Delivery,Obstetrics / Gynecology,"obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,"
Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",Anterior Cervical Discectomy & Interbody Fusion - 2,Neurosurgery,"neurosurgery, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,"
Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema.,"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 Change,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator"
"Patient had some cold symptoms, was treated as bronchitis with antibiotics.","DISCHARGE DIAGNOSES:,1.  Acute respiratory failure, resolved.,2.  Severe bronchitis leading to acute respiratory failure, improving.,3.  Acute on chronic renal failure, improved.,4.  Severe hypertension, improved.,5.  Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1.  Hyperlipidemia.,2.  Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3.  Remote history of carcinoma of the breast.,4.  Remote history of right nephrectomy.,5.  Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics.  Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations.  X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits.  The patient however was hypoxic and required 4L nasal cannula.  She was admitted to the Intensive Care Unit.  The patient improved remarkably over the night on IV steroids and empirical IV Lasix.  Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization.  The patient's breathing has improved.  There is no wheezing or crepitations and O2 saturation is 91% on room air.  The patient is yet to go for exercise oximetry.  Her main complaint is nasal congestion and she is now on steroid nasal spray.  The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction.  The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1.  Metoprolol 25 mg p.o. b.i.d.,2.  Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1.  Prednisone 20 mg p.o. daily for seven days.,2.  Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:,  The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.",Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids,"
"Bronchoscopy with bronchoalveolar lavage.  Refractory pneumonitis.  A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.","PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.",Bronchoscopy & Bronchoalveolar Lavage,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis"
"Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.",Low-Transverse C-Section - 5,Obstetrics / Gynecology,"obstetrics / gynecology, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph,"
A 5-month-old boy brought by his parents because of 2 days of 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.,",A 5-month-old boy with cough,Pediatrics - Neonatal,
"Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.","CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,",Sinus problems - Consult,ENT - Otolaryngology,
Neurologic examination sample.,"NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.",Neurologic Examination,Neurology,"neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE"
"Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.","PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement.  However developed progressive problems and he had two additional stents placed with some initial improvement.  Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY.  He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes.  The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management.  Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient.  Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length.  The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position.  Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion.  The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine.  A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out.  The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly.  Strap muscles were separated in the midline, dissection carried down to visceral fascia.  Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks.  There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable.  There was a markedly enlarged thyroid isthmus.  Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection.  Trachea was exposed from the cricoid to the fourth ring which entered down into the chest.  The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation.  The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness.  The trachea was entered and visualized with thickening of the mucosa and submucosa was noted.  The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered.  Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site.  Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea.  A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis.  After removal of the stents and granulation tissue, the upper trachea was widely patent.  The mid trachea had some marked narrowing secondary to granulation.  Stent material was removed from this area as well.  In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time.  All visible stent material in the upper and mid trachea were removed.  Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third.  Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube.  A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa.  The distal trachea and mainstem bronchi were widely patent.  This secured his airway and no further manipulation felt to be needed at this time.  Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl.  The skin laterally to the trach site was closed with running 2-0 Prolene.  Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition.  The patient tolerated the procedure well without complication.",Tracheostomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airway, laryngology, shiley, alteration of voice, bronchi, bronchoscopy, cannula, cartilage, cricoid, flexible, foreign body, mainstem, obstruction, perichondrium, stenosis, stent, subglottic, swallowing, trachea, tracheal, tracheal stenosis, tracheostomy, shiley single cannula tracheostomy, shiley single cannula, single cannula tracheostomy, thyroid isthmus, stent material, tracheostomy tube, tube, thyroid,"
Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus.,"ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.",Anterior Cervical Discectomy - 2,Neurosurgery,"neurosurgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE"
Patient with immune thrombocytopenia,"SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,",Thrombocytopenia - SOAP Note,Hematology - Oncology,"hematology - oncology, platelets, platelet count, thrombocytopenia, prednisone,"
"Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.","PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,",Hysterectomy & Salpingoophorectomy,Obstetrics / Gynecology,
Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye.,"CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.",Clear Corneal Temporal Incision,Ophthalmology,"ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.","TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.",Laryngectomy & Thyroid Lobectomy,ENT - Otolaryngology,"ent - otolaryngology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage"
"The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.","CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.",Consult - Breast Cancer - 2,Hematology - Oncology,
Small internal hemorrhoids and Ileal colonic anastomosis.,"PROCEDURE PERFORMED: , Colonoscopy and biopsy.,INDICATIONS:,  The patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at Hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  Since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  She has had problems with recurrent seizures and has been seen by Dr. XYZ, who started her recently on methadone.,MEDICATIONS: , Fentanyl 200 mcg, Versed 10 mg, Phenergan 25 mg intravenously given throughout the procedure.,INSTRUMENT: , PCF-160L.,PROCEDURE REPORT: , Informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,A colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  The distal ileum was examined, which was normal in appearance.  Random biopsies were obtained from the ileum and placed in jar #1.  Random biopsies were obtained from the normal-appearing colon and placed in jar #2.  Small internal hemorrhoids were noted within the rectum on retroflexion.,COMPLICATIONS: , None.,ASSESSMENT:,1.  Small internal hemorrhoids.,2.  Ileal colonic anastomosis seen in the proximal transverse colon.,3.  Otherwise normal colonoscopy and ileum examination.,PLAN:, Followup results of biopsies.  If the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with Dr. XYZ, for treatment of her chronic abdominal pains.",Colonoscopy with Biopsy - 2,Gastroenterology,"gastroenterology, proximal transverse, transverse colon, internal hemorrhoids, colonic anastomosis, biopsy, rectum, transverse, hemorrhoids, colonic, anastomosis, abdominal, ileum, biopsies, colonoscopy"
14 years old complaining about severe ear pain - Chronic otitis media.,"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",Ear pain - Pediatric Consult,Pediatrics - Neonatal,
Patient comes for discussion of a screening colonoscopy.,"HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.",Consult - Screening Colonoscopy,Gastroenterology,"gastroenterology, screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy,"
Endovascular Brachytherapy (EBT),"ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis.  The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site.  After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter.  The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy.  The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter.  Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.",Endovascular Brachytherapy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor.,"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.",Craniotomy & Neuronavigation,Neurosurgery,"neurosurgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,"
"Type 1 diabetes mellitus, insulin pump requiring.  Chronic kidney disease, stage III.  Sweet syndrome, hypertension, and dyslipidemia.","PROBLEMS LIST:,1.  Type 1 diabetes mellitus, insulin pump requiring.,2.  Chronic kidney disease, stage III.,3.  Sweet syndrome.,4.  Hypertension.,5.  Dyslipidemia.,6.  Osteoporosis.,7.  Anemia.,8.  A 25-hydroxy-vitamin D deficiency.,9.  Peripheral neuropathy manifested by insensate feet.,10.  Hypothyroidism.,11.  Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  Her last visit to this clinic was approximately three months ago.  Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  Her 14-day average is 191.  She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  She was able to manage this completely on her own.  In the meantime, she is not having any other medical problems that have interfered with glucose control.  Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1.  A number of topical creams for her rash.,2.  Hydroxyzine 25 mg 4 times a day.,3.  Claritin 5 mg a day.,4.  Fluoxetine 20 mg a day.,5.  Ergocalciferol 800 international units a day.,6.  Protonix 40 mg a day.,7.  Iron sulfate 1.2 cc every day.,8.  Actonel 35 mg once a week.,9.  Zantac 150 mg daily.,10.  Calcium carbonate 500 mg 3 times a day.,11.  NovoLog insulin via insulin pump about 30 units of insulin daily.,12.  Zocor 40 mg a day.,13.  Valsartan 80 mg daily.,14.  Amlodipine 5 mg a day.,15.  Plavix 75 mg a day.,16.  Aspirin 81 mg a day.,17.  Lasix 20 mg a day.,18.  Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change.  Her upper respiratory symptoms have resolved.  She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  She is not having any decreased appetite.  She is not having painful urination, any blood in the urine, frequency or hesitancy.  She is not having polyuria, polydipsia or polyphagia.  Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  HEENT:  Examination found her to be atraumatic and normocephalic.  She has pupils that are equal, round, and reactive to light.  Extraocular muscles intact.  Sclerae and conjunctivae are clear.  The paranasal sinuses are nontender.  The nose is patent.  The external auditory canal and tympanic membranes are clear A.U.  Oral cavity and oropharynx examination is free of lesions.  The mucosus membranes are moist.  NECK:  Supple.  There is no lymphadenopathy.  There is no thyromegaly.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  EXTREMITIES:  Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above.  She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  Her target pre-meal is 120 and bedtime is 150.  Her insulin/carbohydrate ratio is 10 and her correction factor is 60.  We are not going to make any changes to her insulin pump settings at this time.  I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  She has agreed to try that and cut back on this a little bit.  I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump.  She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.",Chronic Kidney Disease Followup - 2,Nephrology,
Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.,"ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.",Hip Fracture - Rehab Consult,Orthopedic,
A 2-month-old female with 1-week history of congestion and fever x2 days.,"CHIEF COMPLAINT:,  A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:,  The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week.  The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions.  The mother states that the cough is at times paroxysmal and associated with posttussive emesis.  The patient has had short respiratory pauses following the coughing events.  The patient's temperature has ranged between 102 and 104.  She has had a decreased oral intake and decreased wet diapers.  The brother is also sick with URI symptoms, and the patient has had no diarrhea.  The mother reports that she has begun to regurgitate after her feedings.  She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET:  ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:  ,The patient delivered at term.  Birth weight was 6 pounds 1 ounce.  Postnatal complications:  Neonatal Jaundice.  The patient remained in the hospital for 3 days.  The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes.  There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal.  The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS:  GENERAL: , The patient has had fever, there have been no chills.  SKIN:  No rashes.  HEENT:  Mild congestion x1 week.  Cough, at times paroxysmal, no cyanosis.  The patient turns red in the face during coughing episodes, posttussive emesis.  CARDIOVASCULAR:  No cyanosis.  GI:  Posttussive emesis, decreased oral intake.  GU:  Decreased urinary output.  ORTHO:  No current issues.  NEUROLOGIC:  No change in mental status.  ENDOCRINE:  There is no history of weight loss.  DEVELOPMENT:  No loss of developmental milestones.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL:  This is a well-appearing infant in no acute distress.,HEENT:  Shows anterior fontanelle to be open and flat.  Pupils are equal and reactive to light with red reflex.  Nares are patent.  Oral mucosa is moist.  Posterior pharynx is clear.  Hard palate is intact.  Normal gingiva.,HEART:  Regular rate and rhythm without murmur.,LUNGS:  A few faint rales.  No retractions.  No stridor.  No wheezing on examination.  Mild tachypnea.,EXTREMITIES:  Warm, good perfusion.  No hip clicks.,NEUROLOGIC:  The patient is alert.  Normal tone throughout.  Deep tendon reflexes are 2+/4.  No clonus.,SKIN:  Normal.,LABORATORY DATA:,  CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes.  Electrolytes were within normal limits.  C-reactive protein 0.3.  Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view.  UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN:  ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress.  The patient is currently stable in the emergency room.  We will admit the patient to the pediatric floor.  We will send out pertussis PCR.  We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria.  The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia.  We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.",Congestion & Fever - 2-month-old,Pediatrics - Neonatal,
MRI - Right temporal lobe astrocytoma.,"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.",Astrocytoma,Neurology,"neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,"
H&P for a female with Angina pectoris.,"CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:",H&P - Cardio (Angina),Cardiovascular / Pulmonary,
Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft.,"PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.",Laminectomy & Foraminotomy & Cervical Fusion,Orthopedic,
"Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.","PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.",Symes Amputation - Hallux,Hematology - Oncology,"hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux"
"Laparoscopy with ablation of endometriosis.  Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.","PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.",Laparoscopy - 4,Obstetrics / Gynecology,"obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation"
Bilateral endoscopic proximal shunt revision and a distal shunt revision.,"TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.",Shunt Revision,Neurosurgery,"neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal"
Holter monitoring - For bradycardia and dizziness.,"INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.",Holter Monitoring,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring,"
MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",MRI Brain - Progressive Aphasia,Radiology,
"Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.","PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.",Bunionectomy & Arthrodesis,Orthopedic,
"Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.","DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,4",Physical Therapy - Back Pain,Orthopedic,
"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.","ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.",Pneumonia - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,"
"Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.","PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,",Colonoscopy - 20,Gastroenterology,"gastroenterology, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy"
"Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.","OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.","Esophagogastrectomy, Jejunostomy, & Chest Tubes",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach,"
Followup on chronic kidney disease.,"REASON FOR VISIT:,  Followup on chronic kidney disease.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old gentleman with stage III chronic kidney disease who on his last visit with me presented with classic anginal symptoms.  He was admitted to hospital and found to have an acute myocardial infarction.  He had a complex hospital course, which resulted in cardiac catheterization and two stents being placed.  His creatinine did pop above up to 3 but then came back to baseline.  His hospital stay was also complicated by urinary retention requiring a catheter and Flomax.  He returns today to re-establish care.  Of note, he was noted to have atrial fibrillation while hospitalized and had massive epistaxis.,ALLERGIES:,  None.,MEDICATIONS: , Starlix 120 mg b.i.d., Compazine b.i.d., aspirin 81 mg daily, Plavix 75 mg daily, glipizide 15 mg b.i.d., multivitamin daily, potassium 10 mEq daily, Cozaar 25 mg daily, Prilosec 20 mg daily, digoxin 0.125 mg every other day, vitamin C 250 mg daily, ferrous sulphate 325 mg b.i.d., metoprolol 6.25 mg daily, Lasix 80 mg b.i.d., Flomax 0.4 mg daily, Zocor 80 mg daily, and Tylenol p.r.n.,PAST MEDICAL HISTORY:,1.  Stage III CKD with baseline creatinine in the 2 range.,2.  Status post MI on May 30, 2006.,3.  Coronary artery disease status post stents of the circumflex.,4.  Congestive heart failure.,5.  Atrial fibrillation.,6.  COPD.,7.  Diabetes.,8.  Anemia.,9.  Massive epistaxis.,REVIEW OF SYSTEMS:,  Cardiovascular:  No chest pain.  He has occasional dyspnea on exertion.  No orthopnea.  No PND.  He has occasional edema of his right leg.  He has been dizzy and his dose of metoprolol has been gradually decreased.  GU:  No hematuria, foamy urine, pyuria, frequency, dysuria, weak stream or dribbling.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Pulse 70.  Blood pressure 114/58.  Weight 79.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Irregularly irregular.  No murmurs, rubs, or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  EXTREMITIES:  Trace edema on the right.,LABORATORY DATA: , Dated 07/05/06, hematocrit is 30.2, platelets 380, sodium 139, potassium 4.9, chloride 100, CO2 28, BUN 38, creatinine 2.2, glucose 226, calcium 9.7, and albumin 3.7.,IMPRESSION:,1.  Stage III chronic kidney disease with return to baseline GFR of 31 mL/min.  He is on an ARB.,2.  Coronary artery disease, status post stenting.,3.  Hypertension.  Blood pressures are on the low side at present.  I hesitate to increase his Cozaar although I would do this if tolerated in the future.,4.  Anemia of renal disease.  He is to start Aranesp.,5.  ? Atrial fibrillation.  We discussed anticoagulation issues involved with chronic Afib.  He may be popping in and out or this could just be a sinus arrhythmia.,PLAN:,1.  Check EKG.,2.  Start Aranesp 60 mcg every two weeks.,3.  Otherwise see him in four months.,4.  If EKG shows atrial fibrillation, I wanted to talk to Dr. XYZ about Coumadin.",Chronic Kidney Disease - Followup,Nephrology,
Patient with complaint of symptomatic cholelithiasis.,"ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.",Discharge Summary - Cholelithiasis,Gastroenterology,"gastroenterology, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,"
Stroke in distribution of recurrent artery of Huebner (left),"CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.",CT Brain - Stroke,Radiology,
MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",MRI Brain - Toxoplasmosis,Neurology,
"Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:,  Recurrent angina.  History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:,  6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide.  Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range.  There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1.  Ventriculogram:  Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2.  Right coronary artery:  Dominant.  There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3.  Left coronary artery:  The left main coronary artery showed insignificant disease.  The circumflex arose, showed about 30% proximally.  Left anterior descending arose and the previously placed stent was perfectly patent.  There was a large diagonal branch which showed 90% stenosis in its proximal portion.  There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  He desired that we intervene.,Successful stenting of the left anterior descending, diagonal.  The guide was placed in the left main.  We easily crossed the lesion in the diagonal branch of the left anterior descending.  We advanced, applied and post-dilated the 275 x 13 stent.  Final angiography showed 0% residual at the site of previous 90% stenosis.  The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1.  Successful stenting of the left anterior descending/diagonal.  Initially there was 90% in the diagonal after stenting.  There was 0% residual.  There was a lesion a bit more proximal in the 40% range.,2.  Left anterior descending stent remains patent.,3.  30% in the circumflex.,4.  60% in the right coronary.,5.  Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion.  The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy.  We used 6-French Angio-Seal in the groin.  All questions have been answered.  I have discussed the possibility of restenosis, need for further procedures.","Heart Catheterization, Ventriculography, & Angiography - 2",Cardiovascular / Pulmonary,
Patient in ER due to colostomy failure - bowel obstruction.,"CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of ""heartburn."" He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, ""Fleet enema."" ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.",Colostomy Failure,Gastroenterology,
Ultrasound of pelvis - menorrhagia.,"EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.",Ultrasound - Pelvis,Obstetrics / Gynecology,"obstetrics / gynecology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis"
MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",MRI T-Spine - Spinal Mets,Radiology,
Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus.,"ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.",Anterior Cervical Discectomy - 2,Orthopedic,"orthopedic, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE"
Frontal and lateral views of the hip and pelvis.,"EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.",Slipped Capital Femoral Epiphysis (SCFE),Orthopedic,"orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip"
"Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.","Heart Catheterization, Ventriculography, & Angiography",Cardiovascular / Pulmonary,
"Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.","PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.",Aortobifemoral Bypass,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,"
Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.,"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.",Tesio Hemodialysis Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",MRI T-Spine - Spinal Mets,Neurology,
Well-child check and school physical.,"CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.",School Physical - 2,Pediatrics - Neonatal,
Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail.  Left tibial shaft fracture status post gunshot wound.,"TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY:  ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  The patient was admitted and splinted and had compartment checks.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:,  900.,ESTIMATED BLOOD LOSS:  ,100.,COMPLICATIONS:,  None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL:  ,The patient was met in the preoperative holding area and operative site was marked.  The patient was brought to the operating room and given preoperative antibiotics.  Left leg was then prepped and draped in the usual sterile fashion.  A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  This was advanced and confirmed on the AP and lateral fluoroscopic images.  The opening reamer was then used and the ball-tip guidewire was passed.  The reduction was obtained over a large radiolucent triangle.  After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  At this point, a 10 x 390 mm was passed without difficulty.  The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  The final images were taken with fluoroscopy and a 15-mm end-cap was placed.  The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision.  The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity.  He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.",Intramedullary Nail Fixation,Orthopedic,"orthopedic, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial"
Repair of ruptured globe involving posterior sclera - Sample/Template.,"PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.  ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.",Ruptured Globe Repair - Posterior Sclera,Ophthalmology,"ophthalmology, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe"
"The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.","HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and ""walks like a duck.""  He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years.  He also has had hypercholesterolemia.  He has had Crohn's disease for 25 or 30 years.  He has had a colostomy for four years.  He has arthritis, which is reportedly related to the Crohn's disease.  He has hypertension and coronary artery disease and is status post stent placement.  He has depression.  He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:,  He previously worked with pipeline work, but has been on disability for five years.  He is unsure which symptoms led him to go on disability.  He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  He denies alcohol or illicit drug use.  He lives with his wife.  He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49.  His mother died in her 70s from complications of congestive heart failure.  He has one sister who died during a cardiac surgery two years ago.  He has another sister with diabetes.  He has one daughter with hypercholesterolemia.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion.  He states that he was evaluated by a pulmonologist and had a normal evaluation.  He has occasional night sweats.  His hearing is poor.  He occasionally develops bloody stools, which he attributes to his Crohn's disease.  He also was diagnosed with sleep apnea.  He does not wear his CPAP machine on a regular basis.  He has a history of anemia.  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:  Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance:  He is well appearing in no acute distress.  He has somewhat of a flat affect.,Cardiovascular:  He has 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.,Musculoskeletal:  He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status:  His speech is fluent without dysarthria or aphasia.  He is alert and oriented to name, place, and date.  Attention, concentration, and fund of knowledge are intact.  He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Visual fields are full.  Optic discs are normal.  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:  He has normal muscle bulk and tone.  There is no atrophy.  He has few fasciculations in his calf muscles bilaterally.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  There is no action or percussion myotonia or paramyotonia.,Sensory:  He has absent vibratory sensation at the left toe.  This is diminished at the right toe.  Joint position sense is intact.  There is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  Pinprick is intact.  Romberg is absent.  There is no spinal sensory level.,Coordination:  This is intact by finger-nose-finger or heel-to-shin testing.  He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes:  They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  Plantar reflexes are flexor.  There is no ankle clonus, finger flexors, or Hoffman's signs.  He has crossed adductors bilaterally.,Gait and Stance:  He has a slightly wide-based gait.  He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08:  Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast:  Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08:  Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial.  He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1.  I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2.  I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3.  I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4.  I believe that he needs to undergo psychotherapy for his depression.  It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist.  The patient is very open about proceeding with this suggestion.,5.  He does need to have his sleep apnea better controlled.  He states that he is not compliant because the face mask that he uses does not fit him well.  This should also be addressed.",Multiple Neurological Symptoms,Neurology,
Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.",Bilateral Carotid Cerebral Angiogram,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
"Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.   Bilateral upper lobe cavitary lung masses.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.","PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.",Fiberoptic Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,"
Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar,"INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.",Myoview Perfusion Scan,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion"
"Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.","PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",Anterior Cervical Discectomy & Decompression,Orthopedic,
"Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.","PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.",Radical Hysterectomy,Obstetrics / Gynecology,"obstetrics / gynecology, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments"
Decreased ability to perform daily living activity secondary to recent right hip surgery.,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.",Hip Surgery - Discharge Summar,Orthopedic,
A female with unknown gestational age who presents to the ED after a suicide attempt.,"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",Consult/ER Report - OB/GYN,Obstetrics / Gynecology,
"Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.","REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was ""restless leg syndrome"" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.",Laminectomy & Foraminotomy Followup,Neurology,"neurology, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine,"
"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.","REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",New Onset Seizure,Pediatrics - Neonatal,
Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.,"TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.",Hemicraniectomy,Neurosurgery,"neurosurgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE"
"Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.","PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.","Heart Catheterization, Ventriculography, & Angiography - 10",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography"
"The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.","REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",Neuroblastoma - Consult,Pediatrics - Neonatal,
Ophthalmology followup visit note.,A fluorescein angiogram was ordered at today's visit to rule out macular edema.  We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress.  A copy of the angiogram is enclosed for your records.,Ophthalmology Progress Note - 2,Ophthalmology,"ophthalmology, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, lensesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Cholecystitis with choledocholithiasis.   Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,"REASON FOR ADMISSION: , Cholecystitis with choledocholithiasis.,DISCHARGE DIAGNOSES: , Cholecystitis, choledocholithiasis.,ADDITIONAL DIAGNOSES,1.  Status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  Laparoscopic paraventral hernia in 11/07.,3.  History of sleep apnea with reversal after 100-pound weight loss.,4.  Morbid obesity with bmi of 39.4.,PRINCIPAL PROCEDURE:,  Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,HOSPITAL COURSE: , The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  She subsequently went for a HIDA scan to rule out cholecystitis.  Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  She was taken to the operating room that night for laparoscopic cholecystectomy.  We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  This necessitated conversion to an open operation.  She was transferred to the medical surgical unit postoperatively.  She had a significant amount of incisional pain following morning, but no nausea.  A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid.  White blood cell count was down to 7500 and bilirubin decreased to 2.1.  Next morning she was started on a liquid diet.  Foley catheter was discontinued.  There was no evidence of bile leak from the drains.  She was advanced to a regular diet on postoperative day #3, which was 12/09/07.  The following morning she was tolerating regular diet.  Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  Jackson-Pratt drain was discontinued from the wound.  The remaining Jackson-Pratt drain was left adjacent to her cystic duct.  Following morning, her laboratory studies were better.  Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3.  Jackson-Pratt drain was discontinued, and she was discharged home.  Followup was in 3 days for staple removal.  She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.",Cholecystitis - Discharge Summary,Gastroenterology,"gastroenterology, laparoscopy, common bile duct exploration, laparoscopic cholecystectomy, bile duct, choledocholithiasis, cholecystectomy, cholecystitis, laparoscopic, hernia"
Psychiatric consultation for alcohol withdrawal and dependance.,"REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.",Psych Consult - Alcohol Withdrawal,Psychiatry / Psychology,
"The patient has had abdominal pain associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.","HISTORY OF PRESENT ILLNESS: ,  The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice.  He had epigastric pain and was admitted to the hospital.  A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases.  The patient, additionally, had a questionable pseudocyst in the tail of the pancreas.  The patient underwent ERCP on 04/04/2007 with placement of a stent.  This revealed a strictured pancreatic duct, as well as strictured bile duct.  A 10-french x 9 cm stent was placed with good drainage.  The next morning, the patient felt quite a bit more comfortable.  He additionally had a modest drop in his bilirubin and other liver tests.  Of note, the patient has been having quite a bit of nausea during his admission.  This responded to Zofran.  It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself.  At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000.  His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3.  His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8.  He was tolerating a regular diet.  The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale.  The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary.  He will be further managed for his diabetes there.  The patient will additionally undergo potential end of life meetings.  I discussed the potentials of chemotherapy with patient.  Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity.  The patient will consider this and will discuss this further with Dr. X.  ,DISCHARGE MEDICATIONS:,1.  Phenergan 25 mg q.6. p.r.n.,2.  Duragesic patch 100 mcg q.3.d.,3.  Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4.  Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5.  The patient had initially been on enalapril here.  His hypertension will be managed by Dr. X as well.  ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain.  In the meantime, he will be kept on a regular diet and activity per Dr. X.",Pancreatic Mass - Discharge Summary,Gastroenterology,"gastroenterology, abdominal pain, lymph nodes, weight loss, pancreatic mass, chemotherapy, abdominal, bilirubin, phenergan, stent, drainage,"
"Total hip arthroplasty on the left.  Left hip degenerative arthritis.  Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.","PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.",Total Hip Arthroplasty,Orthopedic,"orthopedic, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,"
"Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.","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.",Anemia - Consult,Hematology - Oncology,
"Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.","PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.",Nerve & Tendon Repair - Finger,Orthopedic,"orthopedic, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,"
HCT for memory loss and for calcification of basal ganglia (globus pallidi).,"CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.",HCT - Calcification of Basal Ganglia,Neurology,"neurology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification,"
"Cataract extraction with lens implantation, right eye.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.","PROCEDURE PERFORMED:,  Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room.  The patient was identified and the correct operative site was also identified.  A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  The patient was prepped and draped in the usual fashion.  A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade.  This was beveled anteriorly in a lamellar fashion using the crescent knife.  Then the anterior chamber was entered with a slit knife.  The chamber was deepened with Viscoat.  Then a paracentesis at the 3 o'clock position was created using a super sharp blade.  A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  I/A proceeded without difficulty using the irrigation/aspiration cannula.  The capsule was felt to be clear and intact.  The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally.  Maxitrol ointment was instilled into the conjunctival sac.  The eye was covered with a double patch and shield, and the patient was discharged.",Cataract Extraction,Ophthalmology,"ophthalmology, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens"
"Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy.  Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.","PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.",D&C & Laparoscopy - 0,Obstetrics / Gynecology,
Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,"PROCEDURES:,  Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding.  Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:,  History and physical examination was performed.  The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATION:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:,  None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  The esophageal mucosa and vascular pattern appeared normal.  The lower esophageal sphincter was located at 25 cm from the central incisors.  It appeared normal.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which distended with excess air.  Rugal folds flattened completely.  Gastric mucosa appeared normal throughout.  No hiatal hernia was noted.  Pyloric valve appeared normal.  The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional 2 biopsies were obtained for CLO testing in the antrum.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of procedure well.  The patient was turned and the scope was advanced with some difficulty to the terminal ileum.  The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  The polyp was severed.  There was no bleeding at the stalk after removal of the polyp head.  The polyp head was removed by suction.  Excess air was evacuated from the colon.  The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN:  ,Histologic evaluation and CLO testing.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.",Esophagogastroduodenoscopy - 3,Gastroenterology,"gastroenterology, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,"
"Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.","FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer.  Her mother died at the age of 67.  She did abuse alcohol.  She had a brother died at the age of 70 from bone and throat cancer.  She has two sons, ages 37 and 38 years old who are healthy.  She has two daughters, ages 60 and 58 years old, both with cancer.  She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,SOCIAL HISTORY: , She is married and has support at home.  Denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Aspirin.,MEDICATIONS:  ,The patient does not list any current medications.,PAST MEDICAL HISTORY: , Hypertension, depression, and osteoporosis.,PAST SURGICAL HISTORY: , She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L.  She is G10, P7, no cesarean sections.,REVIEW OF SYSTEMS: , HEENT:  Headaches, vision changes, dizziness, and sore throat.  GI:  Difficulty swallowing.  Musculoskeletal:  She is right-handed with joint pain, stiffness, decreased range of motion, and arthritis.  Respiratory:  Shortness of breath and cough.  Cardiac:  Chest pain and swelling in her feet and ankle.  Psychiatric:  Anxiety and depression.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Genital:  Negative and noncontributory.,PHYSICAL EXAMINATION:,  On physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds.  BP 138/78, pulse is 64.  General:  A well-developed, well-nourished female, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, she does have some poor dentition.  She does say that she needs some of her teeth pulled on her lower mouth.  Cranial nerves II, III, IV, and VI, vision is intact and visual fields are full to confrontation.  EOMs are full bilaterally.  Pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact, although decreased bilaterally right worse than left.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry.  Normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  She does have some tremoring of her bilateral upper arms as she said.  Strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted.  She is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,It is much more painful for her on the left.  Deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles.  No ankle clonus is elicited.  Hoffmann's is negative bilaterally.  Sensation is intact.  She ambulates with slow short steps.  No spastic gait is noted.  She has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane.  She does not bring one in with her today.,FINDINGS: , Patient brings in cervical spine x-rays and she has had an MRI taken but does not bring that in with her today.  She will obtain that and x rays, which showed at cervical plate C3, C4, C5, C6, and C7 anteriorly with some lifting with the most lifted area at the C3 level.  No fractures are noted.,ASSESSMENT: , Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.,PLAN:,  We went ahead and obtained an EKG in the office today, which demonstrated normal sinus rhythm.  She went ahead and obtained her x-rays and will pick her MRI and return to the office for surgical consultation with Dr. L first available.  She would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery.  All questions and concerns were addressed with her.  Warning signs and symptoms were gone over with her.  If she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled.  I am quite worried about the pain that she is having in her arms, so I would like to see the MRI as well.  Case was reviewed and discussed with Dr. L.",Cervicalgia,Orthopedic,"orthopedic, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing,"
MRI: Right parietal metastatic adenocarcinoma (LUNG) metastasis.,"CC:, Found unresponsive.,HX: ,  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with ""stiff straight arms"" and a ""strange breathing pattern."" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.",MRI of Lung - Adenocarcinoma,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mri, lung, metastatic adenocarcinoma, parietal, breathing pattern, cranial xrt, t1 signal, sensory level, iv load, adenocarcinoma, metastatic, leptomeningeal"
No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,"INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure.  The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia.  He is currently stabilized and improving in strength.  He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program.  He has a few other significant medical problems.,MEDICATIONS:,1.  Toprol-XL 25 mg daily.,2.  Simvastatin 80 mg daily.,3.  Aspirin 81 mg daily.,4.  Synthroid 0.5 mg daily.,5.  Warfarin 1.5 mg daily.,PHYSICAL EXAMINATION: , The patient appears pale and fragile.  He is comfortable at rest.  His resting heart rate is 80.  His resting blood pressure is 112/70.  His conjunctivae are pale.  His lungs have decreased breath sounds throughout and dullness at the bases bilaterally.  Heart exam reveals a distant S1 and S2.  There is a short 2/6 systolic ejection murmur.  The extremities are normal without clubbing, cyanosis or edema.,The resting echocardiogram showed a sinus rhythm at 70 beats per minute.  There is poor R wave progression across the pericardium and Q waves inferiorly.,DESCRIPTION:  ,The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath.  He did not experience chest pain with exercise.  He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate.  His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS.  As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression.  There were no significant ST segment changes with exercise.  There were only rare ventricular premature beats with exercise.,CONCLUSION:,1.  Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,2.  No chest pain with exercise.,3.  No significant ECG changes with exercise.,4.  The patient is considered stable to enter our cardiac rehabilitation program.  I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.",Exercise Stress Test - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial,"
Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",Lumbar Puncture,Neurosurgery,
Diagnostic fiberoptic bronchoscopy.,"PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,",Bronchoscopy - 7,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,"
Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.,"DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.",Delivery Note - 5,Obstetrics / Gynecology,"obstetrics / gynecology, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Patient with mid-epigastric abdominal pain.  Sonogram revealed gallstones.,"PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,",Consult - Laparoscopic Cholecystectomy,Gastroenterology,"gastroenterology, laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal"
Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,"CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.",Cerebral Angiogram,Radiology,
"Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy.  Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.","PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1.  Severe tracheobronchitis.,2.  Mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a.  Right lower lobe bronchoalveolar lavage.,b.  Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite.  The patient had previously been on Coumadin and then heparin.  Heparin was discontinued approximately one-and-a-half hours prior to the procedure.  The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx.  Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure.  Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  The patient was premedicated with 50 mg of Demerol and 2 mg of Versed.  After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  There was minimal redundant oral soft tissue in the oropharynx.  There was mild erythema.  Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied.  Vocal cord motion was normal.  The bronchoscope was then advanced through the larynx into the trachea.  There was evidence of moderate inflammation with prominent vascular markings and edema.  No frank blood was visualized.  The area was suction clear of copious amounts of clear white secretions.  Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  There was significant amount of inflammation, induration, and vascular tortuosity in these regions.  No frank blood was identified.  No masses or lesions were identified.  There was senile bronchiectasis with slight narrowing and collapse during the exhalation.  The air was suctioned clear.  The bronchoscope was withdrawn and advanced into the right main stem.  Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  Again significant amounts of tracheobronchitis was noted with vascular infiltration.  In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  The bronchoscope was removed and advanced into the right middle and right lower lobe.  There was marked injection and inflammation in these regions.  In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  Again, white clear secretions were identified.  No masses or other processes were noted.  The area was suctioned clear.  A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  The bronchoscope was then withdrawn and readvanced into the right upper lobe.  Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  The area remained clear.  No further hemorrhage was identified.  The bronchoscope was subsequently withdrawn.  The patient tolerated the procedure well and was stable throughout the procedure.  No further hemoptysis was identified.  The patient was sent to Recovery in good condition.",Flexible Fiberoptic Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope"
Left elbow manipulation and hardware removal of left elbow.,"PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.",Elbow Manipulation,Orthopedic,"orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware,"
"Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.","FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.",Cholestasis Of Pregnancy,Obstetrics / Gynecology,"obstetrics / gynecology, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis"
Headache.  Right frontal lobe glioma.,"CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with ""bone cancer."" AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.",Glioma - 2,Neurology,"neurology, frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma,"
CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall.,"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,",CT of Lumbar Spine w/o Contrast,Neurology,"neurology, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,"
A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.,"REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general ""OK,"" but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.",Dilated Cardiomyopathy - Consult,Cardiovascular / Pulmonary,
Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes.,"PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.",Tracheostomy & Thyroid Isthmusectomy,ENT - Otolaryngology,"ent - otolaryngology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy"
"Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.","PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.","Heart Catheterization, Ventriculography, & Angiography - 13",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,"
"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.","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.",Attempted Suicide - Consult,Psychiatry / Psychology,
"Pelvic pain, pelvic endometriosis, and pelvic adhesions.  Laparoscopy, Harmonic scalpel ablation of endometriosis, lysis of adhesions, and cervical dilation.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.","PREOPERATIVE DIAGNOSIS:,  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Pelvic endometriosis.,3.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopy.,2.  Harmonic scalpel ablation of endometriosis.,3.  Lysis of adhesions.,4.  Cervical dilation.,ANESTHESIA:  ,General.,SPECIMEN:  ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:,  Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  There are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  There are also adhesions from the omentum to the anterior abdominal wall near the liver.  The uterus and ovaries appear within normal limits other than the adhesions.  The left fallopian tube grossly appeared within normal limits.  The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE:  ,The patient was taken in the operating room and generalized anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  After exam under anesthetic, weighted speculum was placed in the vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  The superior aspect of the umbilicus was grasped with a towel clamp.  The abdomen was tented up and a Veress needle inserted through this incision.  When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle.  This was seen to freely drop in the abdomen so it was connected to CO2 gas.  Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  The abdomen was then insufflated to an adequate distention.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  Next, the laparoscope was inserted through this port.  The medial port was connected to CO2 gas.  Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  Next, a grasper was placed through the suprapubic port.  This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions.  Bowel was carefully examined afterwards and no injuries or bleeding were seen.  Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty.  There was a small amount of bleeding from the anterior abdominal wall peritoneum.  This was ablated with the Harmonic scalpel.  The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  Both of these areas were seen to be hemostatic.  Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  This was sent to pathology.  Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed.  It was seen to be completely hemostatic.  Next, the two size #5 ports were removed under direct visualization.  The camera was removed.  The abdomen was desufflated.  The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.",Laparoscopy,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic pain, endometriosis, pelvic adhesions, laparoscopy, scalpel ablation, lysis of adhesions, cervical dilation, peritoneal biopsy, harmonic scalpel, adhesions, harmonic, scalpel, abdominal, pelvic, abdomen, anterior,"
The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus.  Mild gait impairment and mild cognitive slowing.,"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.",Adult Hydrocephalus,Neurology,
Right and Left carotid ultrasound,"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.",Ultrasound - Carotid - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,"
"Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.","PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.",Rhinectomy & Nasal Endoscopy,ENT - Otolaryngology,"ent - otolaryngology, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue"
Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,"PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.",D&C & Tubal Pregnancy Removal,Obstetrics / Gynecology,"obstetrics / gynecology, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,"
"C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.","PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.",Anterior Cervical Discectomy & Fusion - 7,Orthopedic,"orthopedic, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,"
"Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.","PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.",Total Abdominal Hysterectomy - 1,Obstetrics / Gynecology,"obstetrics / gynecology, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,"
Degenerative disk disease at L4-L5 and L5-S1.  Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,"PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:,  Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED:  ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened.  The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed.  Diskectomy and fusion, which will be separately dictated by Dr. X, were performed.  Once this was completed, all hemostasis was confirmed.  The preperitoneal space was reduced.  X-ray confirmed adequate positioning and fusion.  Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's.  Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.",Diskectomy & Fusion,Orthopedic,"orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,"
Closed reduction and placement of long-arm cast.,"PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,",Long-Arm Cast,Orthopedic,"orthopedic, long-arm cast, closed reduction, displaced fracture, radial deviation, distal radius fracture, arm cast"
Cerebral Angiogram - moyamoya disease.,"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",Moyamoya Disease,Radiology,
Psychiatric consultation for substance abuse.,"REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use.  The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago.  The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over.  The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago.  The patient says he was depressed and agitated.  He says he used cocaine by snorting and nitrous oxide but denies other drug usage.  He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital.  The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure.  The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:,  Substance abuse as per HPI.  The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:,  Seizures.,PAST SURGICAL HISTORY:,  Shoulder injury.,SOCIAL HISTORY:,  The patient lives alone in an apartment uses prior to sobriety 15 months ago.  He was a binge drinker, although unable to provide detail about frequency of binges.  The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:,  None reported.,MEDICATIONS OUTPATIENT:,  Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1.  Gabapentin 300 mg q.8h.,2.  Seroquel 100 mg p.o. q.h.s.,3.  Seroquel 25 mg p.o. q.8h. p.r.n.,4.  Phenergan 12.5 mg IV q.4h. p.r.n.,5.  Acetaminophen 650 mg q.4h. p.r.n.,6.  Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown.  The patient shows psychomotor agitation and is somewhat irritable.  The patient makes fair eye contact and is cooperative.  He had answers my questions with ""I do not know.""  Mood ""depressed"" and ""agitated.""  Affect is irritable.  Thought process logical and goal directed with thought content.  He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  Insight and judgment are both fair.  The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge.  The patient is A&O x3.,ASSESSMENT:,AXIS I:  Substance withdrawal, substance abuse, and substance dependence.,AXIS II:  Deferred.,AXIS III:  History of seizures.,AXIS IV:  Lives alone and unemployed.,AXIS V:  55.,IMPRESSION:,  The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety.  The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1.  Gabapentin 300 mg q.8h. for agitation and history of seizures.,2.  Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult.  Please call with further questions.",Psych Consult - Substance abuse,Psychiatry / Psychology,
Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina.,"PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.",Cardiac Cath & Selective Coronary Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,"
"Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.  Severe degenerative joint disease of the right shoulder.","PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:,  None.  The patient was taken to Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder.  X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  The patient still wanted to proceed forward with surgical intervention.  The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The patient was moved to a beach chair position.  All extremities were well padded.  Her head was well padded to the table.  Her right upper extremity was draped in sterile fashion.  A saber incision was made from the coracoid down to the axilla.  Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  Subscapularis tendon was released.  The humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  A sizer was placed.  It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  This was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  All extra osteophytes were excised.  The supraspinatus and infraspinatus tendons were intact.  Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  The arm had excellent range of motion.  There are no signs of gross dislocation.  Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position.  After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  There was no gross sign of dislocation.  Wound site once again it was copiously irrigated with saline antibiotics.  The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl.  The skin was closed with staples.  A sterile dressing was placed.  The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.",Shoulder Hemi-resurfacing,Orthopedic,"orthopedic, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,"
"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.","Discectomy, Osteophytectomy, & Foraminotomy",Neurosurgery,
A 47-year-old female with a posttraumatic AV in the right femoral head.,"ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.",Discharge Summary - Hip Surgery,Orthopedic,
Left shoulder pain. Evaluate for rotator cuff tear.,"EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:,  Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:,  Unremarkable MRI of the left shoulder.,",MRI Shoulder - 1,Orthopedic,"orthopedic, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear,"
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.,"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.",Subxiphoid Pericardial Window - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,"
"Aortogram with bilateral, segmental lower extremity run off.  Left leg claudication.  The patient presents with lower extremity claudication.","PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.",Aortogram - Leg claudication.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal,"
Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,"NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.","Heart Catheterization, Ventriculography, & Angiography - 4",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography"
Sample of Pulmonary Function Test,"SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,",Pulmonary Function Test - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary,"
Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.,"HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.",URI & Eustachian Congestion,ENT - Otolaryngology,"ent - otolaryngology, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar"
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.,"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 - 7,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic"
"Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.","ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.",D&C - Discharge Summary,Obstetrics / Gynecology,"obstetrics / gynecology, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid,"
Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.,"HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.",Hematology Consult - 1,Hematology - Oncology,
"Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.","PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.",Bronchoscopy - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,"
Problem of essential hypertension.  Symptoms that suggested intracranial pathology.,"SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.",Cardiology Progress Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial,"
Psychiatric History and Physical - Patient with schizoaffective disorder.,"HISTORY OF PRESENT ILLNESS:,  The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of ""manic"" symptoms due to recent medication adjustments.  The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.  In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  She was admitted voluntarily to the inpatient unit and medications were not restarted for her.  On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she ""trust him.""  The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter.  She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  The patient also complains that her daughter is ""trying to tell me what medications to take.""  The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:,  Per chart.  The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then.  It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1.  Seroquel 100 mg, 1 p.o. b.i.d.,2.  Risperdal 1 mg tab, 1 p.o. t.i.d.,3.  Actos 30 mg, 1 p.o. daily.,4.  Lipitor 10 mg, 1 p.o. at bedtime.,5.  Gabapentin 100 mg, 1 p.o. b.i.d.,6.  Glimepiride 2 mg, 1 p.o. b.i.d.,7.  Levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:,  Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:,  The patient is from Brooklyn, New York and moved to Houston approximately one year ago.  She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  She has been married once, but her spouse left her when her three children were young.  Her children are ages 47, 49, and 51.  She had one year of college, and she currently is retired after working in New York public schools for 20 or more years.  She reports that her spouse was physically abusive to her.  She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM:  ,GENERAL:  The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR:  The patient is singing loudly and joking with interviewers.  She is pleasant, but non-cooperative with interview.,SPEECH:  Increased volume, rate, and tone.  Normal in flexion and articulation.  MOTOR:  Agitated.,MOOD:  Okay.,AFFECT:  Elevated and congruent.,THOUGHT PROCESSES:  Tangential and logical at times.,THOUGHT CONTENTS:  Denies suicidal or homicidal ideation.  Denies auditory or visual hallucination.  Positive grandiose delusions and positive paranoid delusions.,INSIGHT:  Poor to fair.,JUDGMENT:  Impaired.  The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:,  Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6.  Acetaminophen level 3.3 and salicylate level less than 0.14.  WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL:  Alert and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT:  Normocephalic and atraumatic.  PERRLA.  EOMI.  MMM.  OP clear.,NECK:  Supple.  No LAD, no JVD, and no bruits.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.  S1 and S2 heard.  No murmurs, rubs, or gallops.,ABDOMEN:  Obese, soft, nontender, and nondistended.  Positive bowel sounds x4.,EXTREMITIES:  No cyanosis, clubbing, or edema.,ASSESSMENT:,  This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa.  The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I:  Schizoaffective disorder.,AXIS II:  Deferred.,AXIS III:  Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV:  Family strife and recent relocation.,AXIS V:  GAF equals 25.,PLAN:",Psych H&P - 3,Psychiatry / Psychology,
Evaluation for right L4 selective nerve root block.,"REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,",Lower Extremity Pain,Orthopedic,
Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only.  He has been referred for cardiac catheterization.,"The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.",Cardiac Catheterization - 12,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac,"
Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained.,"CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.",CT Head and C Spine,Neurology,"neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast"
"Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.","EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS:  ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.",Radiologic Exam - Spine,Neurology,"neurology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral"
Prostate Brachytherapy - Prostate I-125 Implantation,"PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.",Prostate Brachytherapy,Hematology - Oncology,"hematology - oncology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.","TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.",Austin-Akin Bunionectomy,Orthopedic,"orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision,"
Left third digit numbness and wrist pain.,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",MRI C3 - Cord Compression.,Radiology,
"Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.","PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.",Fiberoptic Bronchoscopy - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,"
A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.,"REASON FOR ADMISSION:,  Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma.  The patient has received prior intravenous chemotherapy.  Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy.  She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her.  Therefore, on the last hospitalization for IP chemo, she was switched to Taxol.  The patient since her last visit has done relatively well.  She had no acute problems and has basically only chronic difficulties.  She has had some decrease in her appetite, although her weight has been stable.  She has had no fever, chills, or sweats.  Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease.  She had a recent CT scan of the chest and abdomen.  The report showed the following findings.  In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve.  There was one mildly enlarged mediastinal lymph node.  Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific.  No pulmonary masses were noted.  In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland.  On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted.  There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study.  A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst.  It was unchanged from February and measured 9 mm.  There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable.  Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them.  There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm.  In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter.  No suspicious osseous lesions were noted.,CURRENT MEDICATIONS: , Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.,ALLERGIES: , THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient's height is 165 cm, weight is 77 kg.  BSA is 1.8 sq m.  The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.,GENERAL:  She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time.  She is anicteric.,HEENT:  EOM is full.  Pupils are equal, round, reactive to light and accommodation.  Disc margins are unremarkable as are the ocular fields.  Mouth and pharynx within normal limits.  The TMs are glistening bilaterally.  External auditory canals are unremarkable.,NECK:  Supple, nontender without adenopathy.  Trachea is midline.  There are no bruits nor is there jugular venous distention.,CHEST:  Clear to percussion and auscultation bilaterally.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,BREASTS:  Unremarkable.,ABDOMEN:  Slightly protuberant.  Bowel tones are present and normal.  She has no palpable mass, and there is no hepatosplenomegaly.,EXTREMITIES:  Within normal limits.,NEUROLOGICAL:  Nonfocal.,DIAGNOSTIC IMPRESSION,1.  Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.,2.  Presumed left lower pole kidney hemorrhagic cyst.,3.  History of hypertension.,4.  Type 1 bipolar disease.,PLAN: , The patient will have appropriate laboratory studies done.  A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney.  Interventional radiology will access for ports in the abdomen.  She will receive chemotherapy intraperitoneally.  The plan will be to use intraperitoneal Taxol.",Intraperitoneal Mesothelioma,Hematology - Oncology,"hematology - oncology, chemo, taxol, intraperitoneal mesothelioma, peritoneal mesothelioma, intravenous chemotherapy, adrenal gland, hemorrhagic cyst, peritoneal, intraperitoneal, hemorrhagic, mesothelioma, chemotherapy,"
Chest pain.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.,"INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring.  The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90.  The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs.  The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.,FINDINGS:,1.  Normal hemodynamic response to exercise.,2.  No EKG changes suggestive of ischemia.,3.  No chest pain during the stress test.,4.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.",Exercise Stress Test - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest,"
"Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,","PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.",Meniscoplasty & Chondroplasty,Orthopedic,
MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",MRI Spine - Epidural Lipoma,Orthopedic,
"Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.","DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.",Dobutamine Stress Test - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart"
"The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation.  This pregnancy is a twin gestation.  The patient presents for her fetal anatomical survey.","PAST MEDICAL HISTORY:  ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer.  There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins.  The fetal biometry of twin A is as follows.  The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day.  The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g.  The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g.  The following structures were seen as normal on the fetal anatomical survey.  The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta.  Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day.  There is like gender and a single placenta.  One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications.  We focused our discussion today on the association of twin pregnancy with preterm delivery.  We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation.  We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation.  These are the twins which we have the most concern regarding the long-term prospects of prematurity.  We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction.  We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth.  We discussed the need for frequent office visits to screen for preeclampsia.  We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids.  I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient.  I did review all of the above findings and recommendations with the patient today at the time of her visit.  Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes.",Fetal Anatomical Survey,Obstetrics / Gynecology,"obstetrics / gynecology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound,"
"Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.","TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.",Arthrotomy & Subscapularis Tendon Repair,Orthopedic,"orthopedic, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,"
Transesophageal echocardiogram and direct current cardioversion.,"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.",Transesophageal Echocardiogram,Cardiovascular / Pulmonary,
"Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.","EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.",Angiogram & StarClose Closure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral,"
Right carpal tunnel syndrome.  Right carpal tunnel release.,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.",Carpal Tunnel Release - 7,Orthopedic,"orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,"
"This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.","INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL:",Neonatal Consult,Pediatrics - Neonatal,
Fractured right fifth metatarsal.  Open reduction and internal screw fixation right fifth metatarsal.  Application of short leg splint.,"PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Open reduction and internal screw fixation right fifth metatarsal.,2.  Application of short leg splint.,ANESTHESIA:,  TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal.  The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot.  She continued to walk on the foot and found nothing was wrong despite the pain.  She was recently seen by Dr. X and was referred to Dr. Y for surgery.  The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y.  The consent is available on the chart for review.  The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL:  ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and a sterile stocking was reflected.  Attention was directed to the right fifth metatarsal base.  The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal.  An avulsion fracture of the right fifth metatarsal base was visualized.  The fracture was linear in nature from distal lateral to proximal medial.  There appeared to be a pseudoarthrosis on the lateral view.  A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve.  A linear incision was created with a #10 blade.  A #15 blade was used to deepen the incision through the subcutaneous tissue.  All small veins traversing the subcutaneous tissue were ligated with electrocautery.  Next, using combination of sharp and blunt dissection, the deep fascia was reached.  Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade.  Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone.  The fracture site was not clearly visualized due to bony callus.  A #25 gauge needle was introduced into the fracture site under fluoroscopy.  The fracture site was easily found.  An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone.  Next, a small ball burr was used to resect the remaining hypertrophic bone.  Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone.  Next, a bone clamp was applied and the fracture was reduced.  Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally.  A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly.  All this was done under fluoroscopy.  Next, the wound was flushed with copious amounts of sterile saline.  The fracture site was found to have rigid compression.  The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed.  Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion.  A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique.  Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique.  A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance.  A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot.  Next, copious amounts of Webril were applied to pad all bony prominences.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  Next, 4-inch, pre-moulded, well-padded posterior splint was applied.  The capillary refill time of the digits was less than three seconds.  The patient tolerated the above anesthesia and procedure without complications.  After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone.  She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches.  She will rest, ice, and elevate her right leg.  She is to follow up in the clinic on 08/26/03 at 10:30 a.m..  She was given emergency contact numbers and will call or return if problems arise earlier.",ORIF - Fifth Metatarsal,Orthopedic,"orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif"
"CT abdomen without contrast and pelvis without contrast, reconstruction.","EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.",CT Abdomen & Pelvis - 5,Gastroenterology,"gastroenterology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,"
"Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis.  Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.","PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,5.  Possible adenomyosis.,6.  Left hydrosalpinx.,7.  Suspicion for endometriosis.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  The cyst was not diagnosed as an endometrioma.  The patient does desire future fertility; however, would like a definitive diagnosis.  Conservative medical therapy was offered i.e.  Lupron or repeat oral contraceptives, but declined.,FINDINGS:,  Bimanual exam reveals a small retroverted uterus which is easily mobile.  There were no adnexal masses.  The cervix was normal on palpation.  A fibrotic band was noted at the internal os during dilation.  On laparoscopic exam, the uterus was found to be small with mild spongy texture.  On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  The left ovary was grossly normal.  The left fallopian tube had a mild hydrosalpinx present.  The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  The liver appeared grossly normal.  There were no obvious pelvic adhesions.  The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE:  ,The patient was seen in the preop suite.  History was reviewed and all questions were answered.  The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  She was placed in a dorsal lithotomy position in Allen stirrups.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine.  A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted.  A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  An infraumbilical incision was made using skin scalpel.  The Veress needle was placed and CO2 was insufflated.  It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed.  A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  The #12 port was placed and the laparoscope was inserted.  Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette.  A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  This procedure was performed under direct laparoscopic visualization.  Laparoscopic evaluation of the pelvis was performed and the above findings noted.  A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization.  A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  The manipulator was then removed and the Harmonic scalpel was placed through the #5 port.  The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  The Harmonic scalpel was removed from the abdomen as was the #5 port.  The incision was internally found to be hemostatic.  The laparoscope was then removed from the abdomen.  The abdomen was desufflated.  The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  The weighted speculum was then removed.  The patient taken out of dorsal lithotomy position.  She was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology.  Her family was notified of the findings.  She will be instructed not to have intercourse or use tampons or douche for the next two weeks.  The patient will be sent home with a prescription for Darvocet for pain.",D&C & Laparoscopy - 1,Obstetrics / Gynecology,
Psychiatric consultation for alcohol withdrawal and dependance.,"REASON FOR CONSULT:,  Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal.  The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  He reported that he called 911 secondary to noticing bilious vomiting and dry heave.  The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  He has been away from work secondary to alcohol cravings and drinking.  He has also experienced marital and family conflict as a result of his drinking habit.  On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  He reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings.  The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  He denies depressive symptoms.  He denies any psychotic symptoms or perceptual disturbances.  There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations.  The patient denies any history of suicidal attempts.  There is no history of inpatient rehabilitation programs.  He has attended AA for periodic moments throughout the past few years.  He has been treated with Antabuse before.,PAST MEDICAL HISTORY:,  The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance.  No other psychiatric illnesses in the family.,SOCIAL HISTORY:,  The patient has been divorced twice.  He has two daughters one from each marriage, ages 15 and 22.  He works as a geologist at Petrogas.  He has limited contact with his children.  He reports that his children's mothers have turned them against him.  He and his wife have experienced marital discord secondary to his alcohol use.  His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:,  This is a well-groomed male.  He appears his stated age.  He is lying comfortably in bed.  There are no signs of emotional distress.  He is pleasant and engaging.  There are no psychomotor abnormalities.  No signs of tremulousness.  His speech is with normal rate, volume, and inflection.  Mood is reportedly okay.  Affect euthymic.  Thought content, no suicidal or homicidal ideations.  No delusions.  Thought perception, there are no auditory or visual hallucinations.  Thought process, Logical and goal directed.  Insight and judgment are fair.  The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:,  CBC:  WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000.  BMP:  Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0.  LFTs:  ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  PFTs within normal limits.,IMAGING:,  CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver.  No splenomegaly.,ASSESSMENT:,  This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  The patient currently has no signs of withdrawal.  The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  The patient had severe insomnia that is likely secondary to alcohol use.  Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:,  Axis I:  Alcohol dependence.,Axis II:  Deferred.,Axis III:  Fatty liver, esophagitis, and hypertension.,Axis IV:  Marital discord, estranged from children.,Axis V:  Global assessment of functioning equals 55.,RECOMMENDATIONS:,1.  Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  Discontinue outpatient Restoril.  The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  Continue Alcoholics Anonymous meetings to maintain abstinence.,3.  Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  Supplement with multivitamin, thiamine, and folate upon discharge and before.  Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  Alcohol education and counseling provided during consultation.,6.  Trazodone 50 mg p.o. q.h.s. for insomnia.,7.  Follow up with PCP in 1 to 2 weeks.",Psych Consult - Alcohol Withdrawal,Psychiatry / Psychology,
Complete eye examination - Normal eye and vision exam.,"CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:",Eye Examination - H&P,Ophthalmology,
Central line insertion.  Empyema thoracis and need for intravenous antibiotics.,"PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.",Central Line Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter,"
Endoscopic carpal tunnel release.  Left carpal tunnel syndrome.,"PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.",Endoscopic Carpal Tunnel Rlease,Orthopedic,"orthopedic, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,"
Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",Anterior Cervical Discectomy,Neurosurgery,
"Austin/akin bunionectomy, right foot.  Bunion, right foot.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.","PREOPERATIVE DIAGNOSIS:,  Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:,  Bunion, right foot.,PROCEDURE PERFORMED:,  Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:,  An IV was instituted by Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated to the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was lowered to the operating field and the stockinet was reflected.  The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot.  An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated with hemostasis.  The skin and subcutaneous tissue were then undermined off of the capsule medially.  A dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  The periosteum and capsule were then reflected off of the first metatarsal.  There was noted to be a prominent medial eminence.  The articular cartilage was healthy for patient's age and race.  Attention was then directed to the first interspace where a lateral release was performed..  A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  The adductor tendons were transected as well as a lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  Attention was then directed to medial eminence, which was resected with a sagittal saw.  Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal.  The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  The head was intact.  A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral.  A second K-wire was then inserted from distal lateral to proximal plantar medial.  Adequate fixation was noted at the osteotomy site.  The K-wires were bent, cut, and pin caps were placed.  Attention was then directed to the proximal phalanx of the hallux.  The capsular periostem was reflected off of the base of the proximal phalanx.  A sagittal was then used to create an akin osteotomy closing wedge.  The apex was lateral and the base of the wedge was medial.  The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  Adequate fixation was noted at the osteotomy site and the osteotomy was closed.  The toe was noted to be in a markedly more rectus position.  Sagittal saw was then used to resect the remaining prominent medial eminence.  The area was then smoothed with a reciprocating rasp.  There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site.  The capsule was closed with #3-0 Vicryl.  Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl.  Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  A _______ cast was then applied postoperatively.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  The patient is to follow up with Dr. X in his office as directed.",Bunionectomy - Austin - Akin,Orthopedic,"orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy"
Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation.,"REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.",Cardioversion - Unsuccessful,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial,"
"Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.","CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",Thrombocytosis Followup,Hematology - Oncology,
"Dilatation and curettage (D&C) and Laparoscopic ablation of endometrial implants.  Pelvic pain, hypermenorrhea, and mild pelvic endometriosis.","PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Hypermenorrhea.,3.  Mild pelvic endometriosis.,PROCEDURE PERFORMED:,1.  Dilatation and curettage (D&C).,2.  Laparoscopic ablation of endometrial implants.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMEN: , Endometrial curettings.,INDICATIONS: , This is a 26-year-old female with a history of approximately one year of heavy painful menses.  She did complain of some dyspareunia and wants a definitive diagnosis.,FINDINGS: , On bimanual exam, the uterus is small and anteverted with mildly decreased mobility on the left side.  There are no adnexal masses appreciated.  On laparoscopic exam, the uterus is normal appearing but slightly compressible.  The bilateral tubes and ovaries appear normal.  There is evidence of endometriosis on the left pelvic sidewall in the posterior cul-de-sac.  There was no endometriosis in the right pelvic sidewall or along the bladder flap.,There were some adhesions on the right abdominal sidewall from the previous appendectomy.  The liver margin, gallbladder, and bowel appeared normal.  The uterus was sounded to 9 cm.,PROCEDURE: , After consent was obtained, the patient was taken to the operating room and general anesthetic was administered.  The patient was placed in dorsal lithotomy position and prepped and draped in normal sterile fashion.  Sterile speculum was placed in the patient's vagina.  The anterior lip of the cervix was grasped with vulsellum tenaculum.  The uterus was sounded to 9 cm.  The cervix was then serially dilated with Hank dilators.  A sharp curettage was performed until a gritty texture was noted in all aspects of the endometrium.  The moderate amount of tissue that was obtained was sent to Pathology.  The #20 Hank dilator was then replaced and the sterile speculum was removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  The Veress needle was placed into this incision and the gas was turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  The #11 mm trocar was then placed through this incision and a camera was placed with the above findings noted.  A Bierman needle was placed 2 cm superior to the pubic bone and along the midline to allow a better visualization of the pelvic organs.  A 5 mm port was placed approximately 7 cm to 8 cm to the right of the umbilicus and approximately 3 cm inferior.  The harmonic scalpel was placed through this port and the areas of endometriosis were ablated using the harmonic scalpel.  A syringe was placed on to the Bierman needle and a small amount of fluid in the posterior cul-de-sac was removed to allow better visualization of the posterior cul-de-sac.  The lesions in the posterior cul-de-sac were then ablated using the Harmonic scalpel.  All instruments were then removed.  The Bierman needle and 5 mm port was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar was removed.  The skin was closed with #4-0 undyed Vicryl in subcuticular fashion.  ,Approximately 10 cc of 0.25% Marcaine was placed in the incision sites.  The dilator and vulsellum tenaculum were removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of procedure.  The patient was taken to the recovery room in satisfactory condition.  She will be discharged home with a prescription for Darvocet for pain and is instructed to follow up in the office in two weeks with further treatment will be discussed including approximately six months of continuous monophasic oral contraceptives.",Laparoscopic Ablation of Eendometrial Implants,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic pain, hypermenorrhea, endometriosis, dilatation and curettage, d&c, endometrial implants, ablation, cul de sac, vulsellum tenaculum, hank dilators, laparoscopic ablation, bierman needle, pelvic,"
Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.,"HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.",Abnormal Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress"
"Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.","PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.",Phenol Neurolysis & Botulinum Toxin Injection - 1,Neurosurgery,"neurosurgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol"
Total abdominal hysterectomy (TAH) with a uterosacral vault suspension.   Enlarged fibroid uterus and abnormal uterine bleeding.,"PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT:  ,250 cc of clear urine at the end of the procedure.,FLUIDS:,  2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS:  ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS:  ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally.  The appendix was normal appearing.  The bowel and omentum were normal appearing.  There was no evidence of endometriosis.  Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:,  After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty.  She then underwent a general anesthesia with endotracheal tube also without any difficulty.  She was then examined under anesthesia with noted findings as above.  The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion..  A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis.  This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife.  Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum identified and entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder.  The uterus was markedly evident upon entering the peritoneal cavity.  The uterus was then exteriorized and noted to have the findings as above.  At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps.  Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion.  The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors.  The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic.  The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments.  The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic.  At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors.  Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized.  Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial.  These sutures were then tagged and saved for later.  The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic.  In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic.  At this point, the Lahey clamp was placed on the cervix and the cervix was tented up.  The pubocervical vesical fascia was transacted with long knife.  Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp.  The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps.  The cuff was then copiously painted with Betadine soaked sponge.  The Betadine-soaked sponge was placed in the patient's vagina.  Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff.  This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff.  At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side.  The needle was cut off and these were then tagged with the hemostats.  The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together.  The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff.  The abdomen was copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments.  The abdomen was then once again copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  The sigmoid colon was replaced back into the hollow of the sacrum.  Then the omentum was pulled over the bowel.  After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges.  The GYN Balfour was then removed.  Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic.  The patient would be followed throughout her hospital stay.",Total Abdominal Hysterectomy - 3,Obstetrics / Gynecology,
"He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.","REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.",CAD - 6-Month Followup,Cardiovascular / Pulmonary,
Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,"REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.",Followup Screw Fixation,Orthopedic,"orthopedic, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal"
"Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.","PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",Anterior Cervical Discectomy & Interbody Fusion - 1,Orthopedic,"orthopedic, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical"
"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.","Discectomy, Osteophytectomy, & Foraminotomy",Orthopedic,
"Upper endoscopy, patient with dysphagia.","PROCEDURE:,  Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1.  GERD, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The oropharynx was sprayed with Cetacaine.  The endoscope was passed, under direct visualization, into the esophagus.  The squamocolumnar junction was irregular and edematous.  Biopsies were obtained for histology.  There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  The entire gastric mucosa was normal, including a retroflexed view of the fundus.  The entire duodenal mucosa was normal to the second portion.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Gastroesophageal reflux disease, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies.  The patient was told to continue maintenance Aciphex and anti-reflux precautions.  He will follow up with me on a p.r.n. basis.",Endoscopy - 1,Gastroenterology,"gastroenterology, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,"
The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.  The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,"HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.",Lobectomy - Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer"
Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.,"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.",Pneumoconiosis,Cardiovascular / Pulmonary,
Adenoidectomy procedure,"ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.",Adenoidectomy,ENT - Otolaryngology,"ent - otolaryngology, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.","REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.",CAD - 6-Month Followup,Cardiovascular / Pulmonary,
"T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.","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.",Cancer of the nasopharynx,Hematology - Oncology,"hematology - oncology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,"
A two week well-child check.,"SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.",Well-Child Check - 4,Pediatrics - Neonatal,
"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.","REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",Renal Insufficiency - Consult,Nephrology,
Discharge summary of a patient with mood swings and oppositional and defiant behavior.,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",Psychiatric Discharge Summary - 1,Psychiatry / Psychology,
Carotid Ultrasonic & Color Flow Imaging,"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.",Carotid Doppler Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,"
Status post brain tumor removal.   The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  She had a brain tumor removed and had left-sided weakness.,"DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.",Physical Therapy - Brain Tumor Removal,Neurology,
"Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.","PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.",Resection of Tumor of Scalp,Hematology - Oncology,"hematology - oncology, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor,"
"Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.","PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.",Pelvic Laparotomy,Obstetrics / Gynecology,"obstetrics / gynecology, lysis of pelvic adhesions, salpingooophorectomy, pain-buster pain management system, adnexal mass, pelvic laparotomy, pelvic adhesions, rectus sheath, vicryl sutures, adhesions, pelvic"
"Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.","PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.",Anterior Cervical Discectomy & Decompression - 1,Orthopedic,"orthopedic, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy"
A 27-year-old female with a size and date discrepancy.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:",Ultrasound OB - 7,Radiology,
Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation,Neurology,
Right upper lung lobectomy.  Mediastinal lymph node dissection,"OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.",Lobectomy & Lymph Node Dissection,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches"
MRI report 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.",MRI Cervical Spine - Chiropractic Specific,Neurology,"neurology, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
Echocardiogram was performed including 2-D and M-mode imaging.,"EXAM:,  Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode.  Cardiac chamber dimensions, left atrial enlargement 4.4 cm.  Left ventricle, right ventricle, and right atrium are grossly normal.  LV wall thickness and wall motion appeared normal.  LV ejection fraction is estimated at 65%.  Aortic root and cardiac valves appeared normal.  No evidence of pericardial effusion.  No evidence of intracardiac mass or thrombus.  Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  There is mild tricuspid regurgitation.  Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1.  LV Ejection fraction, estimated at 65%.,2.  Mild left atrial enlargement.,3.  Mild tricuspid regurgitation.,4.  Mildly elevated pulmonary systolic pressure.",Echocardiogram - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram,"
"Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.","PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.",Trabeculectomy & Tenonectomy,Ophthalmology,"ophthalmology, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,"
"Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.","CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.",CT Abdomen & Pelvis - 8,Nephrology,"nephrology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen"
"He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again.","HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , 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:  BP 124/77",Diplopia,Neurology,
Psychiatric Consultation of patient with altered mental status.,"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.",Psych Consult - Altered Mental Status,Psychiatry / Psychology,
Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation,"PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.",Anterior Cervical Discectomy & Osteophytectomy,Orthopedic,
Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.,"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.,",Transesophageal Echocardiography Probe,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe"
"Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.","PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.",Bilateral Myringotomies,ENT - Otolaryngology,"ent - otolaryngology, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,"
"Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.","REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.",High PT-INR - ER Visit,Cardiovascular / Pulmonary,
"Left heart catheterization with ventriculography, selective coronary angiography.  Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.  ,ANTICOAGULATION:  ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery.  All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA:  ,Aortic pressure was in the physiologic range.  No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram:  The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery:  Dominant.  There was insignificant disease in the system.,3. Left coronary:  Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted.  Six-French Angio-Seal was used in the groin.","Heart Catheterization, Ventriculography, & Angiography - 3",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,"
"Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.","TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.",Debridement - Shoulder,Orthopedic,"orthopedic, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,"
Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",Sepsis - Consult,Hematology - Oncology,
Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.,"SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.",Pacemaker (Single Chamber),Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber,"
"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.","CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",Reactive Airway Disease,Pediatrics - Neonatal,
"Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.","PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.","Browlift, Blepharoplasty, & Rhytidectomy",Ophthalmology,"ophthalmology, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,"
Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.,"EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.",Three Views - Foot,Orthopedic,"orthopedic, three views, radiopaque, fractures, foot trauma"
"Laparoscopic tubal sterilization, tubal coagulation.","PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.",Tubal Sterilization & Coagulation,Obstetrics / Gynecology,"obstetrics / gynecology, cervix, cervical stab incision, laparoscopic tubal sterilization, tubal sterilization, tubal coagulation, sterilization, laparoscopic, endometriosis"
"Partial rotator cuff tear, left shoulder.  Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.","PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA:  ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION:  ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon.  There was some softening and loss of the articular cartilage over the glenoid.  The labrum was ________ attached permanently to the glenoid.  The biceps tendon was nonsubluxable.  Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side.  Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space.  There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:,  This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder.  MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position.  After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion.  The left extremity was prepped and draped in usual fashion.  The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect.  We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion.  A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder.  A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula.  The operative findings found intra-articularly were as described previously gross operative findings.  We did not see any evidence of acute pathology.  We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline.  The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal.  All this was done and hemostasis was achieved.  The rotator cuff was examined from the bursal side and showed no evidence of tears.  There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver.  We removed all of our instruments and suctioned the subacromial space dry.  A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling.  She was placed back on the gurney, extubated and taken to the PACU in stable condition.",Arthroscopy - Shoulder,Orthopedic,"orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,"
Transesophageal echocardiogram.   The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,"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 - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve"
a pleasant 62-year-old male with cerebral palsy,"DISCHARGE DIAGNOSES:,1.  Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2.  Prostatic hypertrophy with bladder outlet obstruction.,3.  Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks.  He will be followed in the office.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 62-year-old male with cerebral palsy.  The patient was recently admitted to Hospital with lower extremity cellulitis.  This resolved, however, recurred in both legs.  Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:,  As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION:  ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  Blood culture and wound cultures were unremarkable.  Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin.  On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  A Foley catheter was inserted and was productive of approximately 500 cc of urine.  The patient was prescribed Flomax 0.4 mg daily.  24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.",Discharge Summary - Cerebral Palsy,Neurology,"neurology, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge,"
"Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.","PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.",Temporal Artery Biopsy - 1,Neurosurgery,"neurosurgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,"
Colpocleisis and rectocele repair.,"PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.",Colpocleisis,Obstetrics / Gynecology,"obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,"
Chest pain.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.,"INDICATION: , Chest pain.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring.  The patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90.  The patient was started on a Bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 METs.  The patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no EKG changes, no chest pain.,FINDINGS:,1.  Normal hemodynamic response to exercise.,2.  No EKG changes suggestive of ischemia.,3.  No chest pain during the stress test.,4.  Achieved optimum METs for the exercise done and this is a normal exercise treadmill stress test.",Exercise Stress Test - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, treadmill stress test, heart rate, blood pressure, stress test, treadmill, hemodynamic, ekg, chest,"
Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,"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 - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate,"
"Pars plana vitrectomy, membrane peel, 23-gauge, right eye.","PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:,  The patient had epiretinal membrane causing cystoid macular edema.  Options were discussed with the patient stressing that the visual outcome was guarded.  Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table.  Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified.  Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  The fluid was run.  Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety.  There were no complications.  DVT precautions were in place.  I, as attending, was present in the entire case.",Vitrectomy - 2,Ophthalmology,"ophthalmology, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane,"
Myocardial perfusion imaging - patient had previous abnormal stress test.  Stress test with imaging for further classification of CAD and ischemia.,"CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:,  Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol.  The peak workload was 7 METs.  The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  EKG at rest showed normal sinus rhythm with a right-bundle branch block.  The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery.  There were occasional PVCs, but no sustained arrhythmia.  The patient had an episode of supraventricular tachycardia at peak stress.  The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2.  There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  This appeared to be partially reversible in the resting images.,3.  The left ventricle appeared normal in size.,4.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1.  Average exercise tolerance.,2.  Adequate cardiac stress.,3.  Abnormal EKG response to stress, consistent with ischemia.  No symptoms of chest pain at rest.,4.  Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5.  The patient had run of SVT at peak stress.,6.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.",Myocardial Perfusion Imaging - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion"
Patient in ER complaining of shortness of breath (COPD),"CHIEF COMPLAINT:,  The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation.,PAST MEDICAL HISTORY:,  Hypertension and emphysema.,MEDICATIONS:,  Lotensin and some water pill as well as, presumably, an Atrovent inhaler.,ALLERGIES:,  None are known.,HABITS:,  The patient is unable to cooperate with the history.,SOCIAL HISTORY:,  The patient lives in the local area with his wife.,REVIEW OF BODY SYSTEMS:,  Unable, secondary to the patient’s condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.,GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,HEENT: Head is normocephalic and atraumatic.,NECK: The neck is supple without obvious jugular venous distention.,LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.,ABDOMEN: Soft to palpation.,Extremities: Without edema.,DIAGNOSTIC DATA:,  White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.,Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,CRITICAL CARE NOTE:,  Critical care one hour.,Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range.,All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation.,The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range.,Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol.,Critical care note terminates at this time.,EMERGENCY DEPARTMENT COURSE:,  See the critical care note.,MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS):,  This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded.,COORDINATION OF CARE:,  Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit.,FINAL DIAGNOSIS:,  Respiratory failure secondary to severe chronic obstructive pulmonary disease.,DISCHARGE INSTRUCTIONS:, The patient is to be transferred to the Intensive Care Unit for further management.",ER Report - COPD,Cardiovascular / Pulmonary,
Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,"PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.",Ventriculostomy Placement,Neurology,"neurology, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular"
"Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.","REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.",Biventricular Cardioverter Defibrillator Implantation,Cardiovascular / Pulmonary,
Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.",CT Angiography - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,"
"Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.","PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.",Cataract Extraction - 2,Ophthalmology,"ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,"
"Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.","PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.",Cemented Arthroplasty,Orthopedic,
"Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.","PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.",Anterior Cervical Discectomy & Arthrodesis - 1,Neurosurgery,"neurosurgery, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,"
"Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.","PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.",Anterior Cervical Discectomy & Fusion - 1,Neurosurgery,"neurosurgery, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion"
"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.","PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",Anterior Cervical Discectomy & Fusion - 1,Orthopedic,
"Upper endoscopy with biopsy.   The patient admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.","PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.",Endoscopy With Biopsy,Gastroenterology,"gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,"
Common CT Head template.,"TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are within normal limits.  ,IMPRESSION: , No acute abnormalities.",CT Head,Neurology,"neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE"
"Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.","CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.",Rotator cuff syndrome - H&P,Orthopedic,
Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.,"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.",Pulmonary Hypertension - Pediatric Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary"
Common description of EGD.,"The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.",EGD Template - 2,Gastroenterology,"gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE"
Chronic adenotonsillitis with adenotonsillar hypertrophy.  Upper respiratory tract infection with mild acute laryngitis.,"HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.",Consult - Enlarged Tonsils,ENT - Otolaryngology,
MRI cervical spine.,"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.",MRI Cervical Spine - 1,Orthopedic,"orthopedic, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,"
Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,"PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt ""feverish"" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he ""usually"" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL",Proctitis & Proctocolitis,Gastroenterology,
Tilt table test.  A patient with past medical history of syncope.  The patient is also complaining of dizziness.,"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.",Tilt Table Test - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, vasovagal syncope, tilt table test, blood pressure, heart rate, dizziness,"
"Cataract to right eye.  Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.","PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED:  ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED:  ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA:  ,Topical.,PROCEDURE IN DETAIL:  ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite.  Hemodynamic monitoring was begun.  Time-out was called and the patient eye operated upon and lens implant intended were verbally verified.  Three drops of tetracaine were applied to the operative eye.  The patient was then prepped and draped in usual sterile fashion for intraocular surgery.  A lid speculum was placed.  Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife.  The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat.  The clear corneal temporal incision was fashioned.  The anterior chamber was entered by introducing a keratome.  The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps.  The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique.  Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally.  This area was tamponaded with Healon.  The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse.  An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area.  The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus.  There was noted to be good support.  Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat.  Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly.  The pupil was noted to constrict symmetrically.  Wounds were checked with Weck-cels and found to be free of vitreous.  BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12.  All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous.  A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried.  Lid speculum was removed.  TobraDex ointment, light patch and a Soft Shield were applied.  The patient was taken to the recovery room, awake and comfortable.  We will follow up in the morning for postoperative check.  He will not be given Diamox due to his sulfa allergy.  The intraoperative course was discussed with both he and his wife.",Cataract Extraction & Vitrectomy,Ophthalmology,"ophthalmology, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,"
A 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.,"IDENTIFYING DATA:,  The patient is a 45-year-old white male.  He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , ""I'm in jail because I was wrongly arrested."" The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission.  He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused.  He believes that he has been arrested and is in jail.  Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone.  His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  His partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home.  He reports that the patient has been eating regularly with no recent weight loss.  He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine.  He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  The patient was last enrolled in an outpatient mental health treatment in mid 2009.  He dropped out of care about six months ago when he moved with his partner.  His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was ""useful, but not dosed high enough."" Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  The patient is fairly vague on his history of AIDS related conditions, but does identify the following:  Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner.  He is unemployed.  Details of his educational and occupational history are not currently known.  His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  The patient reports smoking marijuana a few times in his life, but not recently.  Denies other illicit substance use.,LEGAL HISTORY:  ,Unknown.,GENETIC PSYCHIATRIC HISTORY:,  Also unknown.,MENTAL STATUS EXAM:,Attitude:  The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  His appearance is cachectic.  The patient is poorly groomed.,Psychomotor:  There is no psychomotor agitation or retardation.  No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect:  His affect is fairly detached.,Mood:  Describes his mood is ""okay."",Speech:  His speech is normal rate and volume.  Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process:  His thought processes are markedly tangential.,Thought content:  The patient is fairly scattered.  He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  Paranoid delusions are elicited.,Homicidal/Suicidal Ideation:  He denies suicidal or homicidal ideation.  Denies previous suicide attempts.,Cognitive Assessment:  Cognitively, he is alert and oriented to person and year only.  His memory is intact to names of his Madison Clinic providers.,Insight/Judgment:  His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses.  His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets:  His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations:  His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION:  ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I:  Schizophrenia by history.  Rule out AIDS-induced psychosis.  Rule out AIDS-related cognitive disorder.,AXIS II:  Deferred.,AXIS III:  AIDS (stable by his report).  Anemia.,AXIS IV:  Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V:  Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers.  The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis.  With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past.  I anticipate titrating further for effect during the course of his admission.",Psych Consult - Schizophrenia,Psychiatry / Psychology,
"Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.","PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.",Toronto Porcine Valve Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,"
Emergency cesarean section.,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.",Emergency C-section.,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,"
Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.,"PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.",Trigger Thumb Release,Orthopedic,"orthopedic, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision"
Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.,"REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.",Tethered Cord Evaluation,Neurology,"neurology, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,"
Tube Shunt  - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.,"PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.",Tube Shunt - Ahmed Valve Implant,Ophthalmology,"ophthalmology, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus,"
"Echocardiographic examination.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%, mitral annular calcification with structurally normal mitral valve, no intracavitary thrombi is seen, interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.","REASON FOR EXAM:,  CVA.,INDICATIONS: , CVA.,This is technically acceptable.  There is some limitation related to body habitus.,DIMENSIONS:  ,The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,FINDINGS: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%.  The right atrium and right ventricle are normal in size.,Mitral valve showed mitral annular calcification in the posterior aspect of the valve.  The valve itself was structurally normal.  No vegetations seen.  No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1.  The aortic valve showed minimal thickening with good exposure and coaptation.  Peak velocity is normal.  No AI.,Pulmonic and tricuspid valves were both structurally normal.,Interatrial septum was appeared to be intact in the views obtained.  A bubble study was not performed.,No pericardial effusion was seen.  Aortic arch was not assessed.,CONCLUSIONS:,1.  Borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  Mitral annular calcification with structurally normal mitral valve.,3.  No intracavitary thrombi is seen.,4.  Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.",Echocardiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricular hypertrophy, normal wall motion, ventricle, atrium, annular calcification, mitral valve, interatrial septum, hypertrophy, annular, thrombi, ventricular, structurally, septum, valve, mitral,"
"To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.","CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,",Cardiac Consultation - 2,Cardiovascular / Pulmonary,
Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,"PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.",Anterior Cervical Discectomy & Fusion,Orthopedic,"orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior"
Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.,"PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.",Endotracheal Intubation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma"
Tracheotomy for patient with respiratory failure.,"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.",Tracheotomy - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,"
"Austin bunionectomy with internal screw fixation, first metatarsal, left foot.","TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.",Austin Bunionectomy,Orthopedic,"orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,"
"Primary low-transverse C-section.  Postdates pregnancy, failure to progress, meconium stained amniotic fluid.","PREOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,OPERATION:,  Primary low-transverse C-section.,ANESTHESIA:,  Epidural.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner.  Anesthesia was tested and found to be adequate.  Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally.  Bleeders were bovied.  Rectus muscles were separated from the overlying fascia with blunt and sharp dissection.  Muscles were separated in the midline.  Peritoneum was entered sharply and incision was carried out laterally in each direction.  Bladder blade was placed and bladder flap developed with blunt and sharp dissection.  A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction.  Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance.  Infant was carefully suctioned after delivery of the head and body.  Cord blood was collected.  _______ and endometrial cavity was wiped free of membranes and clots.  Lower segment incision was inspected.  There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic.  Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present.  Cul-de-sac was suctioned free of blood and clots and irrigated.  Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated.  Lower segment incision was again inspected and found to be hemostatic.  The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin.  Hemostasis was present between all layers.  The area was gently irrigated across the peritoneum and fascial layers.  There were no intraoperative complications except blood loss.  The patient was taken to the recovery room in satisfactory condition.",Low-Transverse C-Section - 4,Obstetrics / Gynecology,"obstetrics / gynecology, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,"
"This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.","CHIEF COMPLAINT: , ""A lot has been thrown at me."",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.",Huntington's Disease - Consult,Neurology,
"Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.","PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.",Tubal Ligation - Laparoscopic,Obstetrics / Gynecology,"obstetrics / gynecology, tenaculum, uterine manipulator, veress needle, tubal ligation, permanent sterilization, uterus, adnexa, cavity, laparoscope, laparoscopic, needle, sterilization"
Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION:",EMG/Nerve Conduction Study - 9,Radiology,
"Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.","PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.",Septoplasty,ENT - Otolaryngology,"ent - otolaryngology, nasal septal deviation, nasal septal, auricular cartilage, nasal, nasal obstruction, nasal valve, septoplasty, submucoperichondrial, upper airway, internal nasal valve, external nasal valve, hemitransfixion incision, revision septoplasty, septal spur, valve collapse, auricular, cartilage, collapse, septum, valve,"
The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 2,Neurology,
"Hemiarthroplasty, right hip.  Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.","ADMISSION DIAGNOSES:  ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED:  ,Hemiarthroplasty, right hip.,CONSULTATIONS:  ,Medicine for management of multiple medical problems including Alzheimer's.,HOSPITAL COURSE: , The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  The patient was admitted to Orthopedics and consulted Medicine.  The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's.  Brief elevation of white count following the surgery, which did subside.  Studies, UA and blood culture were negative.  The patient was stable and was discharged to Heartland.,CONDITION ON DISCHARGE: , Stable.,DISCHARGE INSTRUCTIONS:,  Transfer to ABC for rehab and continued care.  Diabetic diet.  Activity, ambulate as tolerated with posterior hip precautions.  Rehab potential fair.  He will need nursing, Social Work, PT/OT, and nutrition consults.  Resume home meds, DVT prophylaxis, aspirin, and compression stockings.  Follow up Dr. X in one to two weeks; call 123-4567 for an appointment.",Hemiarthroplasty - Discharge Summary,Orthopedic,"orthopedic, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip,"
"Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.","PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.",Craniotomy - Frontotemporal - 1,Neurosurgery,"neurosurgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,"
"CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.","EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.","CT Head, Facial Bones, Cervical Spine",Orthopedic,"orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical"
"The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.","Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.",ORIF Facial Fractures - Followup,ENT - Otolaryngology,"ent - otolaryngology, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures,"
"Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.","PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.",Ttriple-Lumen Central Line,Gastroenterology,"gastroenterology, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction"
"Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.","HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.",Coarctation of Aorta,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,"
Laparoscopic-assisted vaginal hysterectomy.  Abnormal uterine bleeding.  Uterine fibroids.,"PREOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,POSTOPERATIVE DIAGNOSES,1.  Abnormal uterine bleeding.,2.  Uterine fibroids.,OPERATION PERFORMED: , Laparoscopic-assisted vaginal hysterectomy.,ANESTHESIA: , General endotracheal anesthesia.,DESCRIPTION OF PROCEDURE:  ,After adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure.  A speculum was placed into the vagina.  A single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix.  The uterus was sounded to 10.5 cm.  A #10 RUMI cannula was utilized and attached for uterine manipulation.  The single-tooth tenaculum and speculum were removed from the vagina.  At this time, the infraumbilical area was injected with 0.25% Marcaine with epinephrine and infraumbilical vertical skin incision was made through which a Veress needle was inserted into the abdominal cavity.  Aspiration was negative; therefore the abdomen was insufflated with carbon dioxide.  After adequate insufflation, Veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity.  Through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted.  At this time, the suprapubic area was injected with 0.25% Marcaine with epinephrine.  A 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation.  Evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular.  The fallopian tubes have been previously interrupted surgically.  The ovaries appeared normal bilaterally.  The cul-de-sac was clean without evidence of endometriosis, scarring or adhesions.  The ureters were noted to be deep in the pelvis.  At this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty.  The remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  A similar procedure was carried out on the left with the left uterine cornu identified.  The left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected.  The remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery.  The uterine artery was identified.  It was doubly coagulated with bipolar electrocautery and transected.  The anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection.  At this time, attention was made to the vaginal hysterectomy.  The laparoscope was removed and attention was made to the vaginal hysterectomy.  The RUMI cannula was removed and the anterior and posterior leafs of the cervix were grasped with Lahey tenaculum.  A circumferential injection with 0.25% Marcaine with epinephrine was made at the cervicovaginal portio.  A circumferential incision was then made at the cervicovaginal portio.  The anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty.  The right uterosacral ligament was clamped, transected, and ligated with #0 Vicryl sutures.  The left uterosacral ligament was clamped, transected, and ligated with #0 Vicryl suture.  The parametrial tissue was then clamped bilaterally, transected, and ligated with #0 Vicryl suture bilaterally.  The uterus was then removed and passed off the operative field.  Laparotomy pack was placed into the pelvis.  The pedicles were evaluated.  There was no bleeding noted; therefore, the laparotomy pack was removed.  The uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 Vicryl sutures.  The vaginal cuff was then closed in a running fashion with #0 Vicryl suture.  Hemostasis was noted throughout.  At this time, the laparoscope was reinserted into the abdomen.  The abdomen was reinsufflated.  Evaluation revealed no further bleeding.  Irrigation with sterile water was performed and again no bleeding was noted.  The suprapubic trocar sheath was then removed under laparoscopic visualization.  The laparoscope was removed.  The carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed.  The skin incisions were closed with #4-0 Vicryl in subcuticular fashion.  Neosporin and Band-Aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition.  Estimated blood loss was approximately 100 mL.  There were no complications.  The instrument, sponge, and needle counts were correct.",Vaginal Hysterectomy - Laparoscopic-Assisted,Obstetrics / Gynecology,"obstetrics / gynecology, abnormal uterine bleeding, laparoscopic-assisted vaginal hysterectomy, uterine fibroids, bipolar electrocautery, vaginal hysterectomy, vicryl sutures, tooth, uterine, uterosacral, laparoscope, electrocautery, hysterectomy, laparoscopic, coagulated, vaginal, ligament, transected"
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.,"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.",Atrial Fibrillation - Consult,Cardiovascular / Pulmonary,
"Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.","HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:",Lymphoma - Consult,Hematology - Oncology,
"Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.","REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.",Glioma - Consult,Hematology - Oncology,
"Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.","PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.",Laparoscopic Adrenalectomy,Cardiovascular / Pulmonary,
"Spontaneous vaginal delivery.  Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.","PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.",Spontaneous Vaginal Delivery - 1,Obstetrics / Gynecology,"obstetrics / gynecology, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,"
"Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.","DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.",CVA - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident"
"Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.  Colon cancer screening.  Family history of colon polyps.","OPERATIVE PROCEDURES: , Colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,PREOPERATIVE DIAGNOSES:,1.  Colon cancer screening.,2.  Family history of colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Multiple colon polyps (5).,2.  Diverticulosis, sigmoid colon.,3.  Internal hemorrhoids.,ENDOSCOPE USED: , EC3870LK.,BIOPSIES:  ,Biopsies taken from all polyps.  Hot biopsy got applied to one.  Epinephrine sclerotherapy and snare polypectomy applied to four polyps.,ANESTHESIA: , Fentanyl 75 mcg, Versed 6 mg, and glucagon 1.5 units IV push in divided doses.  Also given epinephrine 1:20,000 total of 3 mL.,The patient tolerated the procedure well.,PROCEDURE:  ,The patient was placed in left lateral decubitus after appropriate sedation.  Digital rectal examination was done, which was normal.  Endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen.  It was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine.  Pedunculated polyp next to it was hard to see and there was a lot of peristalsis.  The scope then was advanced through rest of the transverse colon to ascending colon and cecum.  Terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out.  Ascending colon was unremarkable.  At hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen.  In transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy.  Then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy.  Subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy.  The rest of the splenic flexure and descending colon were unremarkable.  Diverticulosis was again seen with almost constant spasm despite of glucagon.  Sigmoid colon did somewhat hinder the inspection of that area.  Rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large.  Excess of air insufflated was removed.  The endoscope was withdrawn.,PLAN: , Await biopsy report.  Pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.",Colonoscopy - 21,Gastroenterology,"gastroenterology, colon cancer, colon polyps, snare polypectomy, cautery, epinephrine sclerotherapy, transverse colon, polypectomy, colonoscopy, sigmoid, endoscope, sclerotherapy, epinephrine, biopsy,"
Urgent cardiac catheterization with coronary angiogram.,"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.,",Urgent Cardiac Cath,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiac catheterization, coronary angiogram, angiogram"
Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.  Removal of loose bodies.  Medial femoral chondroplasty and meniscoplasty.,"PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,",Anterior Cruciate Ligament Reconstruction,Orthopedic,"orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial"
"Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.","PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.",Ulnar Nerve Transposition,Orthopedic,"orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
"Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.","PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.",Bronchoscopy - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,"
"Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.","CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.",Elbow Pain - Consult,Orthopedic,
Abnormal liver enzymes and diarrhea.  CT pelvis with contrast and ct abdomen with and without contrast.,"EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS:  ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration.  Pre-contrast images through the abdomen were also obtained.,COMPARISON:  ,There were no comparison studies.,FINDINGS:  ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation.  These findings may be secondary to the patient's post cholecystectomy state.  The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology.  There are numerous nonspecific retroperitoneal and mesenteric lymph nodes.  These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel.  This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant.  The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable.  The uterus is not visualized.,IMPRESSION:,1.  Right inguinal hernia containing small bowel.  Partial obstruction is suspected.,2.  Nonspecific retroperitoneal and mesenteric lymph nodes.,3.  Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4.  Diverticulosis without evidence of diverticulitis.,5.  Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6.  Osteopenia and degenerative changes of the spine and pelvis.",CT Abdomen & Pelvis - 11,Gastroenterology,"gastroenterology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,"
Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill.,"HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank ""lots of red wine.""  She states after vomiting, she felt ""fine through the night,"" but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.",Viral Gastroenteritis,Gastroenterology,"gastroenterology, nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill,"
This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",Ultrasound OB - 5,Obstetrics / Gynecology,
"The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.","REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",Neuroblastoma - Consult,Hematology - Oncology,
Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.,"PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.",Bbunionectomy & Metatarsal Osteotomy,Orthopedic,"orthopedic, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,"
A middle-aged female with memory loss.,"FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases.",MRI Brain - Memory Loss,Neurology,"neurology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium,"
Nephrology Consultation - Patient with renal failure.,"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:",Nephrology Consultation - 1,Nephrology,
Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.,"PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.",Adenotonsillectomy - 1,ENT - Otolaryngology,"ent - otolaryngology, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,"
Axial images through the cervical spine with coronal and sagittal reconstructions.,"EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.",CT C-Spine - 1,Orthopedic,"orthopedic, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct,"
"A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.","REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:,  The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.  The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  Denies any edema, chest pain, palpitations, or syncope.  She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:,  Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1.  Acidophilus supplement.,2.  Cholestyramine.,3.  Creon 20 three times daily.,4.  Diovan 160 mg twice daily.,6.  Lantus 10 daily.,7.  Norvasc 5 mg daily.,8.  NovoLog 70/30, 10 units at 12 noon daily.,9.  Pamelor 15 mL every evening.,10.  Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY:  ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease.  The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills.  She has also had some jaundice.  Denies any nausea or vomiting.  Denies any chest pain or abdominal pain.  Denies orthopnea, paroxysmal nocturnal dyspnea or edema.  She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits.  Denies melena or hematochezia.  All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL:  An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS:  Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK:  Her head is atraumatic.  She is normocephalic.  Her neck is supple.  There is no JVD.  No palpable adenopathy or thyromegaly.  There is some icterus of the sclerae bilaterally.  Oral mucosa is moist.,CHEST:  Symmetrical expansion with normal percussion note.  There are no inspiratory crackles or expiratory wheeze.,CARDIAC:  Heart sounds S1 and S2 are regular.  There is a 2/6 systolic murmur heard through the precordium.  There is no gallop or rub.  There is no palpable thrill or retrosternal lift.,ABDOMEN:  Soft, nondistended, and nontender with normal bowel sounds.  No audible bruits.,EXTREMITIES:  No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC:  She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43.  White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000.  Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction.  Previous biliary stent was present.,EKG shows normal sinus rhythm.  There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur.  No previous history of heart disease.  This murmur has occurred in the setting of fever and bacteremia.  The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN:  ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms.  Blood pressure control should be maintained with Diovan and Norvasc.  Potassium should be replaced, and hyponatremia should be on proactive.",Murmur & Bacteremia.,Cardiovascular / Pulmonary,
A 37 year-old female with twin pregnancy with threatened premature labor.,"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",Ultrasound OB - 3,Radiology,
Mother states he has been wheezing and coughing.,"CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with ""have asthma.""  Mother states he has been wheezing and coughing.  They saw their primary medical doctor.  He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  They told to go to the ER if he got worse.  He has had some vomiting and some abdominal pain.  His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,PAST MEDICAL HISTORY:,  Asthma with his last admission in 07/2007.  Also inclusive of frequent pneumonia by report.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , Denied.,MEDICATIONS:  ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home.,FAMILY HISTORY: , No noted exposures.,REVIEW OF SYSTEMS:  ,Documented on the template.  Systems reviewed on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  Oxygen saturation low at 91% on room air.,GENERAL:  This is a well-developed male who is cooperative, alert, active with oxygen by facemask.,HEENT:  Head is atraumatic and normocephalic.  Pupils are equal, round, and reactive to light.  Extraocular motions are intact and conjugate.  Clear TMs, nose, and oropharynx.,NECK:  Supple.  Full painless nontender range of motion.,CHEST:  Tight wheezing and retractions heard bilaterally.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  Soft, nontender.  No masses.  No hepatosplenomegaly.,GENITALIA:  Male genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions or rash.,EXTREMITIES:  Moves all extremities without difficulty, nontender.  No deformity.,NEUROLOGIC:  Symmetric face, cooperative, and age appropriate.,MEDICAL DECISION MAKING:,  The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation.  Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  She is further treated in the emergency department with continued breathing treatments.  At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells.  Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.",Asthma in a 5-year-old,Pediatrics - Neonatal,
"Creation of AV fistula, left wrist in the anatomic snuffbox.","TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula.  She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein.  She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P.  She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T.  She lives with her husband and she also has a son at home and she is a very active lady.  She is right handed.  The plan was to place an AV fistula at the left wrist.  The risks and benefits were fully explained to her.  She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically.  Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist.  The cephalic vein was exposed.  The superficial branch of the radial artery was carefully protected and the radial artery was exposed.  There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture.  There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery.  There were no complications.",AV Fistula - 3,Nephrology,"nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula"
Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,"TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.",Suboccipital Craniectomy,Neurology,"neurology, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor"
MRI L-Spine - Bilateral lower extremity numbness,"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.",Normal L-Spine MRI,Neurology,"neurology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness"
"Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.","PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA).  The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:,  This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  Alternatives to the procedure, including the course of the condition without MUA, were discussed.  The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome.  The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area.  Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  The procedure was completed at the level of TI-TI2.  Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:,  With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  Linear force was used to increase the hip flexion gradually during this maneuver.  Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  This was repeated with the opposite lower extremity.  Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance",Spinal Manipulation,Orthopedic,"orthopedic, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar,"
"The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.","DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS:  ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:,  The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity.  There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees.  Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY:  ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return.  The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT:  ,The patient is a 58-year-old female with left knee osteoarthritis.  Examination indicates deficits in pain, muscle endurance, and functional mobility.  The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN:  ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1.  Modalities including electrical stimulation, ultrasound, heat, and ice.,2.  Therapeutic exercise.,3.  Functional mobility training.,4.  Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1.  The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2.  The patient is to perform standby assist transfer using a pickup walker.,3.  The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4.  The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to be independent with the home exercise program.,2.  The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3.  The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:,  Fair to good.,The above treatment plan has been discussed with the patient.  She is in agreement.",Physical Therapy - Osteoarthritis,Orthopedic,
"An 18-year-old white female who presents for complete physical, Pap, and breast exam.","SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.",Complete Physical - Female,Obstetrics / Gynecology,
H&P for a female with Angina pectoris.,"CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:",H&P - Cardio (Angina),Cardiovascular / Pulmonary,
A 34-year old female with no fetal heart motion noted on office scan.,"FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician.",Ultrasound OB - 2,Obstetrics / Gynecology,"obstetrics / gynecology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal"
Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.,"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.",Stress Test Adenosine Myoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan"
MRI left knee.,"EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles.",MRI Knee - 3,Orthopedic,"orthopedic, mri left knee, interstitial sprain/partial tear, anterior cruciate ligament, lateral meniscus, cruciate ligament, synovial, mri, meniscus, sprain/partial, cruciate, knee, ligament"
"Abdominal pain right lower quadrant, radiating around her side to her right flank.  Etiology is unclear.","REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.",Lower Quadrant Pain,Gastroenterology,
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",Metastatic Ovarian Cancer - Consult,Hematology - Oncology,
Left lower lobectomy.,"OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.",Lobectomy - Left Lower,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,"
MRI Brain and Brainstem - Falling (Multiple System Atrophy),"CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly ""losing"" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for ""tumor."" 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future.",MRI Brain and Brainstem,Neurology,"neurology, myerson's sign, falling, dysautonomia, mri brain and brainstem, brain and brainstem, mri brain, sinemet cr, mri, brainstem, ctr, tumor, retropulsion, parkinsonism, brain, lightheadedness, hypophonia, standing, sinemet,"
"Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.","HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.",Neurologic Consultation - 3,Neurology,
MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.",MRI Brain & Cerebral Angiogram,Radiology,
Left little finger extensor tendon laceration.  Repair of left little extensor tendon.,"PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.",Extensor Tendon Repair,Orthopedic,"orthopedic, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor,"
"Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa.  Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.","PREOPERATIVE DIAGNOSIS:  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Right cubital tunnel syndrome.,2.  Right carpal tunnel syndrome.,3.  Right olecranon bursitis.,PROCEDURES:,  ,1.  Right ulnar nerve transposition.,2.  Right carpal tunnel release.,3.  Right excision of olecranon bursa.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS: , Thickened transverse carpal ligament and partially subluxed ulnar nerve.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion.  After elevation and exsanguination with an Esmarch, the tourniquet was inflated.  The carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues.  The palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally.  A Freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,After adequate release has been formed, the wound was irrigated and closed with nylon.  The medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected.  A medial antebrachial cutaneous nerve was identified and protected throughout the case.  The ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed.  The ulnar nerve was freed proximally and distally.  The medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided.  The intraarticular branch and the first branch to the SCU were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns.  The fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight.  The wound was irrigated.  The tourniquet was deflated and the wound had excellent hemostasis.  The subcutaneous tissues were closed with #2-0 Vicryl and the skin was closed with staples.  Prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa.  A posterior splint was applied.  Marcaine was injected into the incisions and the splint was reinforced with tape.  He was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.",Ulnar Nerve Transposition & Olecranon Bursa Excision,Orthopedic,"orthopedic, cubital tunnel syndrome, carpal tunnel syndrome, olecranon bursitis, ulnar nerve transposition, carpal tunnel release, excision of olecranon bursa, transposition, ligament, tourniquet, excision, bursa, syndrome, subcutaneous, ulnar, olecranon, carpal, nerve, tunnel,"
"Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.  Right hyoid mass, rule out carcinomatosis.  Chronic obstructive pulmonary disease.  Changes consistent with acute and chronic bronchitis.","PREOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Right hyoid mass, rule out carcinomatosis.,2.  Weight loss.,3.  Chronic obstructive pulmonary disease.,4.  Changes consistent with acute and chronic bronchitis.,5.  Severe mucosal irregularity with endobronchial narrowing of the right middle and lower lobes.,6.  Left vocal cord irregularity.,PROCEDURE PERFORMED:  ,Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe.,ANESTHESIA: , Demerol 50 mg with Versed 3 mg as well as topical cocaine and lidocaine solution.,LOCATION OF PROCEDURE: , Endoscopy suite #4.,After informed consent was obtained and following the review of the procedure including procedure as well as possible risks and complications were explained and consent was previously obtained, the patient was sedated with the above stated medication and the patient was continuously monitored on pulse oximetry, noninvasive blood pressure, and EKG monitoring.  Prior to starting the procedure, the patient was noted to have a baseline oxygen saturation of 86% on room air.  Subsequently, she was given a bronchodilator treatment with Atrovent and albuterol and subsequent saturation increased to approximately 90% to 91% on room air.,The patient was placed on a supplemental oxygen as the patient was sedated with above-stated medication.  As this occurred, the bronchoscope was inserted into the right naris with good visualization of the nasopharynx and oropharynx.  The cords were noted to oppose bilaterally on phonation.  There was some slight mucosal irregularity noted on the vocal cord on the left side.  Additional topical lidocaine was instilled on the vocal cords, at which point the bronchoscope was introduced into the trachea, which was midline in nature.  The bronchoscope was then advanced to the distal trachea and additional lidocaine was instilled.  At this time, the bronchoscope was further advanced through the main stem and additional lidocaine was instilled.  Bronchoscope was then further advanced into the right upper lobe, which revealed no evidence of any endobronchial lesion.  The mucosa was diffusely friable throughout.  Bronchoscope was then slowly withdrawn into the right main stem and additional lidocaine was instilled.  At this point, the bronchoscope was then advanced to the right bronchus intermedius.  At this time, it was noted that there was severe mucosal irregularities of nodular in appearance significantly narrowing the right lower lobe and right middle lobe opening.  The mucosal area throughout this region was severely friable.  Additional lidocaine was instilled as well as topical epinephrine.  At this time, bronchoscope was maintained in this region and endobronchial biopsies were performed.  At the initial attempt of inserting biopsy forceps, some resistance was noted within the proximal channel at this time making advancement of the biopsy forceps out of the proximal channel impossible.  So the biopsy forceps was withdrawn and the bronchoscope was completely withdrawn and new bronchoscope was then utilized.  At this time, bronchoscope was then reinserted into the right naris and subsequently advanced to the vocal cords into the right bronchus intermedius without difficulty.  At this time, the biopsy forceps were easily passed and visualized in the right bronchus intermedius.  At this time, multiple mucosal biopsies were performed with some mild oozing noted.  Several aliquots of normal saline lavage followed.  After completion of multiple biopsies there was good hemostasis.  Cytology flushing was also performed in this region and subsequently several aliquots of additional normal saline lavage was followed.  Bronchoscope was unable to be passed distally to the base of the segment of the right lower lobe or distal to the further visualized endobronchial anatomy of the right middle lobe subsegments.  The bronchoscope was then withdrawn to the distal trachea.,At this time, bronchoscope was then advanced to the left main stem.  Additional lidocaine was instilled.  The bronchoscope was advanced to the left upper and lower lobe subsegments.  There was no endobronchial lesion visualized.  There is mild diffuse erythema and fibromucosa was noted throughout.  No endobronchial lesion was visualized in the left bronchial system.  The bronchoscope was then subsequently further withdrawn to the distal trachea and readvanced into the right bronchial system.  At this time, bronchoscope was readvanced into the right bronchus intermedius and additional aliquots of normal saline lavage until cleared.  There is no gross bleeding evidenced at this time or diffuse mucosal erythema and edema present throughout.  The bronchoscope was subsequently withdrawn and the patient was sent to recovery room.  During the bronchoscopy, the patient noted ________ have desaturation and required increasing FiO2 with subsequent increased saturation to 93% to 94%.  The patient remained at this level of saturation or greater throughout the remaining of the procedure.,The patient postprocedure relates having some intermittent hemoptysis prior to the procedure as well as moderate exertional dyspnea.  This was confirmed by her daughter and mother who were also present at the bedside postprocedure.  The patient did receive a nebulizer bronchodilator treatment immediately prebronchoscopy and postprocedure as well.  The patient also admitted to continued smoking in spite of all of the above.  The patient was extensively counseled regarding the continued smoking especially with her present symptoms.  She was advised regarding smoking cessation.  The patient was also placed on a prescription of prednisone 2 mg tablets starting at 40 mg a day decreasing every three days to continue to wean off.  The patient was also administered Solu-Medrol 60 mg IV x1 in recovery room.  There was no significant bronchospastic component noted, although because of the severity of the mucosal edema, erythema, and her complaints, short course of steroids will be instituted.  The patient was also advised to refrain from using any aspirin or other nonsteroidal anti-inflammatory medication because of her hemoptysis.  At this time, the patient was also advised that if hemoptysis were to continue or worsen or develop progressive dyspnea, to either contact myself, , or return to ABCD Emergency Room for evaluation of possible admission.  However, the above was reviewed with the patient in great detail as well as with her daughter and mother who were at the bedsite at this time as well.",Fiberoptic Flexible Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx"
Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura.,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",Hematoma Evacuation,Neurosurgery,
The patient with atypical type right arm discomfort and neck discomfort.,"INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.",Cardiac Catheterization - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian,"
Chest tube talc pleurodesis of the right chest.,"PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.",Pleurodesis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube"
MRI left shoulder.,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,",MRI Shoulder - 5,Orthopedic,"orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons"
"The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.","HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.",EMG/Nerve Conduction Study - 1,Neurology,"neurology, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction,"
"Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.","PREOPERATIVE DIAGNOSES:,  OM, chronic, serous, simple or unspecified.  Adenoid hyperplasia.  Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:,  The procedure, benefits, and risks were discussed in detail preoperatively.  The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position.  After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  The opposite ear was then cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  Cortisporin suspension was placed in both ear canals.,Then the patient was intubated.  A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand.  The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate.  The adenoid fossa was visualized with the mirror.  The adenoids were removed using the microdebrider.  Two adenoid packs were placed.  The packs were removed one by one.  Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic.  The tenaculum was placed on the superior pole of the right tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  The tenaculum was then placed on the superior pole of the left tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube.  The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.",Bilateral Myringotomies - 1,ENT - Otolaryngology,"ent - otolaryngology, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum"
"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.","DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.",Mastoiditis - Discharge Summary,ENT - Otolaryngology,
"Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,","PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.",Meniscoplasty & Chondroplasty,Orthopedic,
Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.,"REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.",Consult - Atrial Fibrillation,Cardiovascular / Pulmonary,
Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,"PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.",Fiberoptic Bronchoscopy with Lavage,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory,"
"Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.","SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.",SOAP - Numbness & Tingling,Neurology,"neurology, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling"
Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",Anterior Cervical Discectomy & Fusion - 5,Neurosurgery,
Multiple stent placements with Impella circulatory assist device.,"PROCEDURE PERFORMED:,1.  Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile manner.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein.  Through the arterial sheath, angiography of the right common femoral artery was obtained.  Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique.  Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view.  Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS:  ,1.  LV-gram:  LVEDP was 15 mmHg.  LV ejection fraction 10% to 15% with global hypokinesis.  Only anterior wall is contracting.  There was no mitral regurgitation.  There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  The left main coronary artery calcified vessel with disease.,2.  The left anterior descending artery had an 80% to 90% mid-stenosis.  First diagonal branch had a more than 90% stenosis.,3.  The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle.  The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire.  The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch.  The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD.  The stent delivery balloon was used to post-dilate the overlapping segment.  The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  At this point, it was noted that the left main had a retrograde dissection.  A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery.  The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained.  Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained.  Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened.  From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  The right common femoral artery and vein sheaths were both sutured in place for further observation.  Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1.  Left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications.  The estimated blood loss was 200 ml.  Estimated dye used was 200 ml of Visipaque.  The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN:  ,1.  Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2.  Hydration.,3.  The patient will be observed over night for any hemodynamic instability or ischemia.  If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.",Multiple Stent Placements,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,"
MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",MRI Brain - SLE & Stroke,Radiology,
"Excision of nasal tip basal carcinoma, previous positive biopsy.","PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.",BCCa Excision - Nasal Tip,Hematology - Oncology,"hematology - oncology, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal"
"White male with onset of chest pain, with history of on and off chest discomfort over the past several days.","INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.",Cardiac Catheterization - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,"
"Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.","ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.",Gastroenteritis - Discharge Summary,Gastroenterology,"gastroenterology, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids"
Consultation for evaluation of thrombocytopenia.,"REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.",Thrombocytopenia - Consult,Hematology - Oncology,
Common CT Chest template,"TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion.  The aorta and great vessels are normal in caliber.  The central pulmonary arteries are patent with no evidence of embolus.  There is no significant mediastinal, hilar, or axillary lymphadenopathy.  The trachea and mainstem bronchi are patent.  The esophagus is normal in course and caliber.  The lungs are clear with no infiltrates, effusions, or masses.  There is no pneumothorax.  Scans through the upper abdomen are unremarkable.  The osseous structures in the chest are intact.  ,IMPRESSION: , No acute abnormalities.",CT Chest,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE"
"Hardware removal, right ulnar","PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:,  The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 5-month-old male who sustained a both-bone forearm fracture in September 2007.  The fracture healed uneventfully, but then the patient subsequently suffered a refracture one month ago.  The patient had shortening in arms, noted in both bones.  The parents opted for surgical stabilization with nailing.  This was performed one month ago on return visit.  His ulnar nail was quite prominent underneath the skin.  It was decided to remove the ulnar nail early and place the patient in another cast for 3 weeks.,Risks and benefits of the surgery were discussed with the mother.  Risk of surgery incudes risks of anesthesia, infection, bleeding, changes in sensation in most of the extremity, need for longer casting.  All questions were answered and mother agreed to above plan.,PROCEDURE IN DETAIL:  ,The patient was seen in the operative room, placed supine on operating room table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  The left elbow was prepped and draped in a standard surgical fashion.  A small incision was made over the palm with K-wire.  This was removed without incident.  The wound was irrigated.  The bursitis was curetted.  Wounds closed using #4-0 Monocryl.  The wound was clean and dry, dressed with Xeroform 4 x 4s and Webril.  Please note the area infiltrated with 0.25% Marcaine.  The patient was then placed in a long-arm cast.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN:  ,The patient will maintain the cast for 3 more weeks.  Intraoperative nail was given to the mother.  The patient to take Tylenol with Codeine as needed.  All questions were answered.,",Hardware Removal - Ulnar,Orthopedic,"orthopedic, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar,"
"Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.","PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.",Phalanx Amputation,Orthopedic,"orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal"
"Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.","REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.",Elevated BNP - Consult,Cardiovascular / Pulmonary,
Chronic headaches and pulsatile tinnitus.,"HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus.  The patient reports she has been having daily headaches since 02/25/2008.  She has been getting pulsations in the head with heartbeat sounds.  Headaches are now averaging about three times per week.  They are generally on the very top of the head according to the patient.  Interestingly, she denies any previous significant history of headaches prior to this.  There has been no nausea associated with the headaches.  The patient does note that when she speaks on the phone, the left ear has ""weird sounds.""  She feels a general fullness in the left ear.  She does note pulsation sounds within that left ear only.  This began on February 17th according to the patient.  The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family.  The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks.  Interestingly, there has been no significant drop or change in her hearing.  She does report she has had dizzy episodes in the past with nausea, being off balance at times.  It is not associated with the pulsations in the ear.  She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear.  She is denying any vision changes.  The headaches are listed as moderate to severe in intensity on average about three to four times per week.  She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Hypercholesterolemia.,PULMONARY:  Negative.,GASTROINTESTINAL:  Pertinent for nausea.,GENITOURINARY:  The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC:  History of dizziness and the headaches as listed above.,VISUAL:  Negative.,DERMATOLOGIC:  History of itching.  She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:,  She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:,  Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married.  She works at Eye Center as a receptionist.  She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL:  The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  There is an old mastoidectomy scar, left ear.  The ear canals are clean and dry.  Drums intact and mobile.  Weber exam is midline.  Grossly hearing is intact.  Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL:  Reveals clear drainage.  Deviated nasal septum to the left, listed as mild to moderate.  Ostiomeatal complexes are patent and turbinates are healthy.  There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy.  See fiberoptic nasopharyngoscopy separate exam.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION:  ,1.  Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology.  Consider, also normal pressure hydrocephalus.,2.  Recurrent headaches.,3.  Deviated nasal septum.,4.  Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet.  I have also ordered a carotid ultrasound study as part of the workup and evaluation.  She has had a recent CAT scan of the brain though this was without contrast.  It did reveal previous mastoidectomy, left temporal bone, but no other mass noted.  I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related.  Hearing protection devices should be used at all times as well.  I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues.  I am going to recheck her in three weeks.  If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office.  She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.",Consult - Pulsatile Tinnitus,ENT - Otolaryngology,
Ligation and stripping of left greater saphenous vein to the level of the knee.  Stripping of multiple left lower extremity varicose veins.  Varicose veins.,"PREOPERATIVE DIAGNOSIS:,  Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1.  Ligation and stripping of left greater saphenous vein to the level of the knee.,2.  Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:,  None.,BRIEF HISTORY:,  This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity.  The patient has had painful varicose veins for number of years.  He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins.  It was recommended that the patient undergo a saphenous vein ligation and stripping.  He was explained the risks, benefits, and complications of the procedure including intractable pain.  He gave informed consent to proceed.,OPERATIVE FINDINGS:,  The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee.  Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly.  Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE:  ,The patient was marked preoperatively in the Preanesthesia Care Unit.  The patient was brought to the operating suite, placed in the supine position.  The patient underwent general endotracheal intubation.  After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline.  A diagonal incision was created in the direction of the inguinal crease on the left.  A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified.  The vein was isolated with a right angle.  The vein was followed proximally until a multiple tributary branches were identified.  These were ligated with #3-0 silk suture.  The dissection was then carried to the femorosaphenous vein junction.  This was identified and #0 silk suture was placed proximally and distally and ligated in between.  The proximal suture was tied down.  Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein.  An incision was created at the level of the knee.  The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated.  The distal end of the vein stripping device was then passed through at its most proximal location.  The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity.  Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg.  Multiple incisions were created with a #15 blade scalpel.  The incisions were carried down with electrocautery.  Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified.  The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed.  Additionally, some segments were removed.  The stripping approach would be vein stripping device.  Multiple branches of the saphenous vein were then ligated and/or removed.  Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat.  Bleeding was controlled with direct pressure.  All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture.  The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions.  The leg was then wrapped with a sterile Kerlix.  Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression.  The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition.  He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.",Saphenous Vein - Ligation & Stripping,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated,"
"Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.","PREOPERATIVE DIAGNOSIS:,  Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:,  General via endotracheal tube.,BLOOD LOSS:,  Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and laid supine.  General anesthesia was accomplished.  A 16-French Foley was placed using aseptic technique.  The patient was then placed on the operating table prone.  His right flank was prepped and draped in a sterile fashion.  At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed.  The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire.  The wire would not go down the ureter.  Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained.  After multiple attempts, access was lost.  At this point, the tubes were left out of the kidney and sterile dressings were applied.  The patient was then placed on another operating table supine.  His genitalia were prepped and draped after removing his Foley catheter.  Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous.  The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope.  The wire was removed.  Contrast injection with good placement in the collecting system.  The wire was replaced.  The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance.  The wire was removed leaving the double-J stent in good position.  _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated.  The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.",Cysto & Double-J Stent Insersion,Nephrology,"nephrology, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french"
"Adenotonsillectomy, primary, patient under age 12.","PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:,  Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron.  She was placed supine on the operating room table.  General endotracheal anesthesia was induced without difficulty.  In the holding area, her allergies were reviewed.  It is unclear whether she is actually allergic to penicillin.  Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine.  She might be allergic to BACTRIM and SULFA.  After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand.  There was no bifid uvula or submucous cleft.  She had 3+ cryptic tonsils with significant debris in the tonsillar crypts.  Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume.  The left superior tonsillar pole was then grasped with curved Allis forceps.  _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3.  Mouthgag was released, reopened, no bleeding was seen.  The right tonsil was then removed in the same fashion.  The mouthgag released, reopened, and no bleeding was seen.  Small red rubber catheter in the nasal passage was used to retract the soft palate.  She had mild-to-moderate adenoidal tissue residual.  It was removed with Coblation Evac Xtra gently curved Wand on 9/5.  Red rubber catheter was then removed.  Mouthgag was again released, reopened, no bleeding was seen.  Orogastric suction carried out with only scant clear stomach contents.  Mouthgag was then removed.  Teeth and lips were inspected and were in their preoperative condition.  The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:,  Family will be counseled postoperatively.  Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain.  _______ and promethazine if needed for nausea and vomiting.",Adenotonsillectomy,ENT - Otolaryngology,"ent - otolaryngology, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,"
Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.,"PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.",Pacemaker (Dual Chamber) - 2,Cardiovascular / Pulmonary,
"Exam under anesthesia with uterine suction curettage.  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.","PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:,  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,INDICATIONS:  ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05.  The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  She began to have heavy vaginal bleeding and intense lower pelvic cramping.  She was seen in the emergency room where she was found to be hemodynamically stable.  On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  There were bulging membranes protruding through the dilated cervix.  These symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  These findings were reviewed with her and options for treatment discussed.  She elected to proceed with an exam under anesthesia with uterine suction curettage.  The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE:  ,The patient was taken to the operating room where she was placed in the seated position.  A spinal anesthetic was successfully administered.  She was then moved to a dorsal lithotomy position.  She was prepped and draped in the usual fashion for the procedure.  After adequate spinal level was confirmed, a bimanual exam was again performed.  This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  The previously noted cervical exam was confirmed.  The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  This solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  The anterior cervical lip was then attached with a ring clamp.  The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  The placental tissue was then gently tractioned out as well.  A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  The sharp curette was then utilized to probe the endometrial surface.  A small amount of additional tissue was then felt in the posterior uterine wall.  This was curetted free.  A second pass was then made with a vacuum curette.  Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip.  There was only a small amount of bleeding following the curettage.  The weighted speculum was then removed as well.  The bimanual exam was repeated and good involution was noted.  The patient was taken down from the dorsal lithotomy position.  She was transferred to the recovery room in stable condition.  The sponge and instrument count was performed and found to be correct.  The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation.  The estimated blood loss for the procedure is less than 10 mL.",Uterine Suction Curettage,Obstetrics / Gynecology,"obstetrics / gynecology, spontaneous, incomplete abortion, uterine suction curettage, fetus, anterior cervical lip, spontaneous incomplete abortion, bimanual exam, ring clamp, suction curettage, uterine, curettage, suction"
"Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.","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.",Stress Test Dobutamine Myoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion,"
"Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.","REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.",Biventricular Cardioverter Defibrillator Implantation,Cardiovascular / Pulmonary,
"Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.","DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.",Mastoiditis - Discharge Summary,Pediatrics - Neonatal,
"Percutaneous endoscopic gastrostomy tube.  Protein-calorie malnutrition.  The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.","PREOPERATIVE DIAGNOSIS:,  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSIS: , Protein-calorie malnutrition.,PROCEDURE PERFORMED:, Percutaneous endoscopic gastrostomy (PEG) tube.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY:  ,The patient is a 73-year-old male who was admitted to the hospital with some mentation changes.  He was unable to sustain enough caloric intake and had markedly decreased albumin stores.  After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  He was placed in the supine position and was given IV sedation by the Anesthesia Department.  An EGD was performed from above by Dr. X.  The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method.  The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization.  The needle was removed and a guidewire was inserted through the sheath.  The guidewire was grasped from above with a snare by the endoscopist.  It was removed completely and the Ponsky PEG tube was secured to the guidewire.,The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall.  There was no evidence of bleeding.  Photos were taken.  The Bolster was placed on the PEG site.  A complete dictation for the EGD will be done separately by Dr. X.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.",PEG Tube,Gastroenterology,"gastroenterology, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, peg tube, malnutrition, nutritional"
The patient with atypical type right arm discomfort and neck discomfort.,"INDICATIONS FOR PROCEDURE:, The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. Duplex ultrasound showed at least a 50% stenosis.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation with cardiac catheterization protocol. Local infiltration with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 ml.,ESTIMATED CONTRAST:, Less than 250 ml.,PROCEDURE PERFORMED:, Right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 French Angio-Seal placement.,DESCRIPTION OF PROCEDURE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was introduced into the right femoral artery via the modified Seldinger technique.,AORTIC ARCH ANGIOGRAM:, Next, a pigtail catheter was advanced to the aortic arch. Aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 PSI in the 4 degree LAO view.,SELECTIVE SUBCLAVIAN ANGIOGRAPHY:, Next, the right subclavian was selectively cannulated. It was injected in the standard AP, as well as the RAO view. Next pull back pressures were measured across the right subclavian stenosis. No significant gradient was measured.,ANGIOGRAPHIC DETAILS:, The right brachiocephalic artery was patent. The proximal portion of the right carotid was patent. The proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis.,IMPRESSION:,1. Moderate grade stenosis in the right subclavian artery.,2. Patent proximal edge of the right carotid.",Cardiac Catheterization - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discomfort, subclavian stenosis, artery, french angio-seal, lao view, rao view, aortic arch angiogram, arch angiogram, cardiac catheterization, aortic arch, brachiocephalic, cardiac, angiography, aortic, angiogram, stenosis, catheterization, atypical, subclavian,"
"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.","CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",Reactive Airway Disease,Cardiovascular / Pulmonary,
"Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.","REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.",Hematology Consult,Hematology - Oncology,
Colon cancer screening and family history of polyps.  Sigmoid diverticulosis and internal hemorrhoids.,"PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.",Colonoscopy - 10,Gastroenterology,gastroenterology
Consult and Spinal fluid evaluation in a 15-day-old,"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",Spinal fluid evaluation,Pediatrics - Neonatal,
"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","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.",Sick Sinus Syndrome,Cardiovascular / Pulmonary,
Discharge summary of a patient with a BRCA-2 mutation.,"DISCHARGE DIAGNOSES:,  BRCA-2 mutation.  ,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old with a BRCA-2 mutation.  Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION:  ,The chest was clear.  The abdomen was nontender.  Pelvic examination shows no masses.  No heart murmur.  ,HOSPITAL COURSE:  ,The patient underwent surgery on the day of admission.  In the postoperative course she was afebrile and unremarkable.  The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN:  ,The patient will remain at rest initially with progressive ambulation after.  She will avoid lifting, driving or intercourse.  She will call me if any fevers, drainage, bleeding, or pain.  Follow up in my office in four weeks.  Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.",BRCA-2 mutation,Hematology - Oncology,"hematology - oncology, brca-2 mutation, brca-2, mutation, breast cancer, brca mutation, breast, postoperative, peritoneum, brca, discharge, cancer,"
"Hawkins IV talus fracture.  Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.","PREOPERATIVE DIAGNOSIS:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1.  Open reduction internal fixation of the talus.,2.  Medial malleolus osteotomy.,3.  Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:,  50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:,  A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament.  There was no evidence of osteochondral defects of the talar dome.,HISTORY:  ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement.  There was no open injury.  The patient fell approximately 10 feet off his liner, landing on his left foot.  There was evidence of gross deformity of the ankle.  An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture.  He was distal neurovascularly intact.  The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  Because of its tenuous blood supply, the patient is at risk for avascular necrosis.  The patient has agreed to undergo the above-named procedure and consent was obtained.  All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03.  A spinal anesthetic was administered.  A nonsterile tourniquet was placed on the left upper thigh, but not inflated.  He was then positioned on the beanbag.  The extremity was then prepped and draped in the usual sterile fashion for this procedure.  An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg.  At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  This was curved anteromedial along the root of the saphenous vein.  The saphenous vein was located.  Its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  At this time, we identified the medial malleolus.  There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  This pedicle was the anterior portion of the deltoid ligament.  At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus.  Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  This provided us with excellent exposure to the fracture site of the medial side.  At this time, any loose comminuted pieces were removed.  The dome of the talus was also checked and did not reveal any osteochondral defects.  There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  At this time, a reduction was performed.  The #7-0 partially threaded cannulated screws were used in order to fix the fracture.  At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  A depth gauze was then used to measure screw length.  A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction.  This projection gave us excellent view of our screw placement and excellent compression across the fracture site.  At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft.  This was placed using a freer elevator into the fracture site where the comminution was.  At this time, we copiously irrigated the wound.  The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  A tight repair was performed of the deltoid ligament.  At this time, again copious irrigation was used to irrigate the wound.  A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied.  The patient was then placed in a plaster splint for mobilization.  The tourniquet was then released.  The patient was then transferred off the operating table to recovery in stable condition.  The prognosis for this fracture is guarded.  There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  The patient is aware of this and he will be followed as an outpatient for this problem.",ORIF - Talus,Orthopedic,"orthopedic, deltoid ligament, medial malleolus osteotomy, open reduction internal fixation of the talus, hawkins iv talus fracture, medial malleolus, fracture site, malleolus, talus, medial, fracture, tourniquet, ligament, osteotomy,"
"Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.","CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.",Well-woman checkup,Obstetrics / Gynecology,
Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,"PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.",Esophagogastroduodenoscopy - 4,Gastroenterology,"gastroenterology, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy"
Echocardiogram with color flow and conventional Doppler interrogation.,"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.",Echocardiogram,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation,"
"A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.","CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.",Status Epilepticus,Neurology,
Psychosocial evaluation of kidney donor.  Questions - Answers,"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",Psychosocial Eval - Donor,Nephrology,
"Patient had some cold symptoms, was treated as bronchitis with antibiotics.","DISCHARGE DIAGNOSES:,1.  Acute respiratory failure, resolved.,2.  Severe bronchitis leading to acute respiratory failure, improving.,3.  Acute on chronic renal failure, improved.,4.  Severe hypertension, improved.,5.  Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1.  Hyperlipidemia.,2.  Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3.  Remote history of carcinoma of the breast.,4.  Remote history of right nephrectomy.,5.  Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics.  Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations.  X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits.  The patient however was hypoxic and required 4L nasal cannula.  She was admitted to the Intensive Care Unit.  The patient improved remarkably over the night on IV steroids and empirical IV Lasix.  Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization.  The patient's breathing has improved.  There is no wheezing or crepitations and O2 saturation is 91% on room air.  The patient is yet to go for exercise oximetry.  Her main complaint is nasal congestion and she is now on steroid nasal spray.  The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction.  The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1.  Metoprolol 25 mg p.o. b.i.d.,2.  Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1.  Prednisone 20 mg p.o. daily for seven days.,2.  Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:,  The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.",Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids,"
"Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.","TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.",CABG,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Well-child check and school physical.,"CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.",School Physical - 3,Pediatrics - Neonatal,
Left retrosigmoid craniotomy and excision of acoustic neuroma.,"PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.",Craniotomy - Retrosigmoid,Neurology,"neurology, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor"
Patient with complaint of left knee pain.  Patient is obese and will be starting Medifast Diet.,"CHIEF COMPLAINT:,  Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain.  She is approximately five days after a third Synvisc injection.  She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension.  Rates her pain in her knee as a 10/10.  She does alternate ice and heat.  She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1.  PENICILLIN.,2.  KEFLEX.,3.  BACTRIM.,4.  SULFA.,5.  ACE BANDAGES.,MEDICATIONS,1.  Toprol.,2.  Xanax.,3.  Advair.,4.  Ventolin.,5.  Tylenol No.  3.,6.  Advil.,REVIEW OF SYSTEMS:,  Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first.  Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL:  This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect.  She is well developed, well nourished, appears her stated age.,EXTREMITIES:  Orthopedic evaluation of the left knee reveals there to be well-healed portholes.  She does have some medial joint line swelling.  Negative ballottement.  She has significant pain to palpation of the medial joint line, none of the lateral joint line.  She has no pain to palpation on the popliteal fossa.  Range of motion is approximately -5 degrees to 95 degrees of flexion.  It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right.  She has a click with McMurray.  Negative anterior-posterior drawer.  No varus or valgus instability noted.  Positive patellar grind test.  Calf is soft and nontender.  Gait is stable and antalgic on the left.,ASSESSMENT,1.  Osteochondral defect, torn meniscus, left knee.,2.  Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee.  I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction.  She questions whether she needs a total knee; I don't believe she needs total knee replacement.  She may, however, at some point need an arthroscopy.  I have encouraged her to start formal physical therapy and a home exercise program.  Will use ice or heat p.r.n.  I have given her refills on Tylenol No.  3, Flector patch, and Relafen not to be taken with any other anti-inflammatory.  She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily.  She will follow up in our office in four weeks.  If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy.  The patient shows a good understanding of this treatment plan and agrees.",Consult - Knee Pain,Orthopedic,"orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee,"
Noncontrast CT head due to seizure disorder.,"EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain.",CT Head - 1,Neurology,"neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast,"
"Orthopedic progress note for follow up of osteoarthritis, knees.","CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:",Osteoarthritis - Progress Note,Orthopedic,
Sample of Pulmonary Function Test,"SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,",Pulmonary Function Test - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary,"
Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.",Neuroplasty,Orthopedic,"orthopedic, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
"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.","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.",Thromboendarterectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE"
Pain management for post-laminectomy low back syndrome and radiculopathy.,"Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice.  For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient.  The patient was seen late because he had not filled in the patient questionnaire.  To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998.  At that time, he was driving an 18-wheeler truck.  The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer.  He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1.  The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember.  He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005.  At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles.  Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital.  He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2.  This was done on 12/15/2005.  Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot.  He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg.  The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily.  The patient states that he is experiencing no side effects from medications and takes medications as required.  He has apparently been drug screened and his drug screening has been found to be normal.  The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center.  At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression.  There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors.  It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications.  Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes.  Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations.  He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes.  The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis.  This was done by Rhonda Ackerman, Ph.D., a psychologist.  It was also suggested at that time that the patient should quit smoking.  Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs.  Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings.  His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls.  It was felt that any surgical interventions should be put on hold at that time.  In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program.  The evaluation was done by a physician at that time, whose report is clearly documented in the record.  Evaluation was done by Dr. B.  At present, Mr. XYZ continues on with his oxycodone and Norco.  These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks.  The patient states that there has been no recent change in either the severity or the distribution of his pain.  He is unable to sleep because of pain and his activities of daily living are severely limited.  He spends most of his day lying on the floor, watching TV and occasionally will walk a while.  ***** from detailed questioning shows that his activities of daily living are practically zero.  The patient denies smoking at this time.  He denies alcohol use or aberrant drug use.  He obtains no pain medications from no other sources.  Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly.  There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:,  Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus.  The patient does not know what medications he is taking for diabetes and denies any diabetes.  CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction.  History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:,  The patient is on disability.  He does not smoke.  He does not drink alcohol.  He is single.  He lives with a girlfriend.  He has minimal activities of daily living.  The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:,  No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite.  Depressive symptoms of crying and decreased self-worth have been noted in the past.  No neurological history of strokes, epileptic seizures.  Genitourinary negative.  Gastrointestinal negative.  Integumentary negative.  Behavioral, depression.,PHYSICAL EXAMINATION:,  The patient is short of hearing.  His cognitive skills appear to be significantly impaired.  The patient is oriented x3 to time and place.  Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61.  The patient is complaining of pain of a 9/10.,Musculoskeletal:  The patient's gait is markedly antalgic with predominant weightbearing on the left leg.  There is marked postural deviation to the left.  Because of pain, the patient is unable to heel-toe or tandem gait.  Examination of the neck and cervical spine are within normal limits.  Range of motion of the elbow, shoulders are within normal limits.  No muscle spasm or abnormal muscle movements noted in the neck and upper extremities.  Head is normocephalic.  Examination of the anterior neck is within normal limits.  There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles.  Skin is normal.  Hair distribution normal.  Skin temperature normal in both the upper and lower extremities.  The lumbar spine curvature is markedly flattened.  There is a well-healed central scar extending from T12 to L1.  The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles.  Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right.  Range of motion testing of the lumbar spine is labored in all directions.  It is interesting that the patient cannot flex more than 5  in the standing position, but is able to sit without any problem.  There is a marked degree of sciatic notch tenderness on the left.  No abnormal muscle spasms or muscle movements were noted.  Patrick's test is negative bilaterally.  There are no provocative facetal signs in either the left or right quadrants of the lumbar area.  Neurological exam:  Cranial nerves II through XII are within normal limits.  Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes.  Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left.  There is no ankle clonus.  Babinski is negative.  Sensory testing shows a minimal degree of sensory loss on the right L5 distribution.  Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5.  Ankle extensors are -3 on the left and +5 on the right.  Dorsiflexors of the left ankle are +2 on the left and +5 on the right.  Straight leg raising test is positive on the left at about 35 .  There is no ankle clonus.  Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory:  Breath sounds normal.  Trachea is midline.,Cardiovascular:  Heart sounds normal.  No gallops or murmurs heard.  Carotid pulses present.  No carotid bruits.  Peripheral pulses are palpable.,Abdomen:  Hernia site is intact.  No hepatosplenomegaly.  No masses.  No areas of tenderness or guarding.,IMPRESSION:,1.  Post-laminectomy low back syndrome.,2.  Left L5-S1 radiculopathy.,3.  Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4.  Opioid dependence for pain control.,TREATMENT PLAN:,  The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone.  I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment.  I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy.  The prognosis here for any improvement or return to work is zero.",Pain Management Consult - 1,Orthopedic,"orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,"
"Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.","PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.",Tailor Bunionectomy with Screw Fixation,Orthopedic,"orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,"
A two week well-child check.,"SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.",Well-Child Check - 3,Pediatrics - Neonatal,
Stroke in distribution of recurrent artery of Huebner (left),"CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.",CT Brain - Stroke,Radiology,
Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,"PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.",Lumbar Re-exploration,Orthopedic,"orthopedic, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,"
Modified radical mastectomy.  An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.,"PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.  Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  The skin incision was carried down to the subcutaneous fat but no further.  Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl.  The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  The axilla was then cleared of its contents by sharp dissection.  Small vessels entering the axillary vein were clipped and divided.  The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  The long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  The long thoracic nerve represented the posterior most aspect of the dissection.  As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  The dissection continued caudally until the entire specimen was freed and delivered from the operative field.  Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples.  A dressing was applied.  The drains were placed on ""grenade"" suction.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",Radical Mastectomy - 1,Obstetrics / Gynecology,"obstetrics / gynecology, latissimus dorsi muscle, pectoralis major muscle, pectoralis fascia, axillary vein, thoracic nerve, radical mastectomy, pectoralis major, axillary, incision, mastectomy, fascia, muscle, pectoralis,"
Followup of laparoscopic fundoplication and gastrostomy.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.,"REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis.  Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty.  Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007.  She has done well since that time.  She has had some episodes of retching intermittently and these seemed to be unpredictable.  She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved.  The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube.  She seems otherwise happy and is not having an excessive amount of stools.  Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent.  Her belly is soft and nontender.  All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection.  We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty.  The site of the gastrostomy is excellent.  There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy.  Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future.  If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN:  ,The patient will follow up as needed for problems related to gastrostomy.  We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future.",Fundoplication & Gastrostomy Followup,Gastroenterology,"gastroenterology, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,"
Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to 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",Acute Inferior Myocardial Infarction,Cardiovascular / Pulmonary,
"Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.","PROCEDURE:,  Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male.  He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease.  Previous ST elevation MI.,REVIEW OF SYSTEMS.,  The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1.  Visipaque 361 mL total dose.,2.  Clopidogrel bisulphate (Plavix) 225 mg PO,3.  Promethazine (Phenergan) 12.5 mg total dose.,4.  Abciximab (Reopro) 10 mg IV bolus,5.  Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6.  Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1.  Balloon catheter utilized:  Manufacturer:  Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2.  Cordis Vista Brite Tip 6Fr JR 4.0,3.  ACS/Guidant Sport .014"" (190cm) Wire,4.  Stent utilized:  Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:,  The overall left ventricular systolic function is mildly reduced.  Left ventricular ejection fraction is 40% by left ventriculogram.  Mild hypokinesis of the anterior wall of the left ventricle.  There was no transaortic gradient.  Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY:  ,  There were no obstructing lesions in the left main coronary artery.  Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery.  A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  Post-procedure stenosis was 0%.  There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:,  The right coronary artery is dominant to the posterior circulation.  There were no obstructing lesions in the right coronary artery.  Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1.  Severe two-vessel coronary artery disease.,2.  Severe left anterior descending coronary artery disease.  There was a 95% mid left anterior descending artery stenosis.  The lesion was successfully stented.,3.  Moderate left circumflex artery disease.  There was a 50% left circumflex artery stenosis.  Intervention not warranted.,4.  The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1.  Clopidogrel (Plavix) 75 mg PO daily for 1 year.",Cardiac Cath & Coronary Angiography,Cardiovascular / Pulmonary,
"The patient is 14 months old, comes in with a chief complaint of difficulty breathing.","HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",Difficulty Breathing - ER Visit,Cardiovascular / Pulmonary,
"Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.",Angiography & Catheterization,Cardiovascular / Pulmonary,
The patient admitted with palpitations and presyncope.,"HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,",Consult - Palpitations & Presyncope,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart"
Laparoscopic appendectomy.  Acute suppurative appendicitis.  A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:,  This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain.  On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  However, the patient with additional history of loose stools for several days prior to event.  Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.  With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy.  She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach.  The appendix itself noted to have a significant inflammation about it.  There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:,  The patient was placed in supine position.  After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg.  The Veress needle was then removed.  A 10 mm trocar was then introduced through this incision into the abdomen.  A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant.  This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  Through this port, the dissector was utilized to create a small window in the mesoappendix.  Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure.  Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it.  The appendix was then removed from the 12 mm port site and taken off the surgical site.  The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated.  The base of the appendix was reevaluated and noted to be hemostatic.  Aspiration of warm saline irrigant then done and noted to be clear.  There was a small adhesion appreciated in the region of the surgical site.  This was taken down with blunt dissection without difficulty.  There was no evidence of other areas of disease.  Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  The instruments were removed from the patient and the port sites were then taken off under direct visualization.  The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2.  Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.",Appendectomy Laparoscopic - 1,Gastroenterology,"gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis"
"Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.","PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",Laminectomy & Foraminotomy Revision,Orthopedic,
A 10 years of age carries a diagnosis of cystic fibrosis,"INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.",Cystic Fibrosis,Cardiovascular / Pulmonary,
Patient with palpitations and rcent worsening of chronic chest discomfort.,"CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.",Chest discomfort & palpitations - Consult.,Cardiovascular / Pulmonary,
A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:,  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.",MRI Shoulder - 4,Orthopedic,"orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear,"
"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.","REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 1,Neurology,
Lumbar puncture with moderate sedation.,"PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After ""time out"" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.",Lumbar Puncture - 1,Neurosurgery,"neurosurgery, moderate sedation, lumbar puncture, needle, lumbar,"
"GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.","PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.",GI Consultation - 2,Gastroenterology,
The patient was exercised according to standard Bruce protocol for 9 minutes.,"REASON FOR EXAMINATION:,  Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate.  Peak blood pressure was 132/60.  The patient did not experience any chest discomfort during stress or recovery.  The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram.  Technetium was injected at 5 minutes into stress.,IMPRESSION:,1.  Good exercise tolerance.,2.  Adequate heart rate and blood pressure response.,3.  This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,",Treadmill Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram,"
Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.,"CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:",T-Cell Lymphoma Consult,Hematology - Oncology,"hematology - oncology, t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck,"
"Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.","REASON FOR CONSULTATION:,  Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  Patient used to take medicine for hyperlipidemia and then that was stopped.  He used to live in Canada and he moved to Houston four months ago.  He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  It lasts around 10-15 minutes at times.  It is 5/10 in quality.  It is not associated with shortness of breath, nausea, vomiting, or sweating.  It is not also associated with food.  He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  No palpitations, syncope or presyncope.  He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  No fever, chills, cough, hemoptysis, hematemesis or hematochezia.  His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:,  Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease.  His father died in his 50s with an acute myocardial infarction.,MEDICATION:,  Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:,  No known allergies.,REVIEW OF SYSTEMS:,  As mentioned above,EXAMINATION:,  This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt:  239",Cardiac Consultation - 4,Cardiovascular / Pulmonary,
Evaluation for chronic pain program,"REASON FOR EVALUATION:,",Knee & Back Pain,Orthopedic,
A 14-year-old young lady is in the renal failure and in need of dialysis.,"PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.",Peritoneal Dialysis Catheter Insertion,Nephrology,"nephrology, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal"
"Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.","PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.",Craniotomy - Occipital,Neurosurgery,"neurosurgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,"
Holter monitoring - For bradycardia and dizziness.,"INDICATION: , Bradycardia and dizziness.,COMMENTS:,1.  The patient was monitored for 24 hours.,2.  The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  There was a frequent premature ventricular contraction seen.  Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  During rest of the monitoring period, there were just occasional premature ventricular contractions seen.  No ventricular tachycardia was seen.,5.  There were no pathological pauses noted.,6.  The longest RR interval was 1.1 second.,7.  There were no symptoms reported.",Holter Monitoring,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring,"
A sample note on serous otitis media,"Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay.  Children begin to speak some words by 18 months.  Children with fluid in both ears can show significant delay in their use of language.  In addition, young children learn to pronounce words by hearing them spoken.  When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.  Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear.  Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly.  Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms.  Therefore, it is essential that ear infections be rechecked after initial treatment.  Usually, the presence of fluid results in a ""mild conductive hearing loss."" This could be as much as 30% hearing loss overall.  After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised.  This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.  If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated.  The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope.  Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted.  The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.",SOM - Serous Otitis Media,ENT - Otolaryngology,"ent - otolaryngology, tube, bmt, pet, pressure equalizing tubes, serous otitis media, eustachian tube, ear infections, otitis media, middle ear, hearing loss, ear, children, fluid, drain, eustachian, otitis, media, eardrum, infections, middle, loss, hearingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.",Preop Cardiac Consult,Cardiovascular / Pulmonary,
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",Metastatic Ovarian Cancer - Consult,Obstetrics / Gynecology,
Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,"HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was ""rebuilt."" He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, ""natural"" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.",Cervical Cord Lesion - Consult,Neurology,
"Medical management, status post left total knee arthroplasty.","REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1.  Polyarthritis.,2.  Acromegaly.,3.  Hypothyroidism.,4.  Borderline hypertension.,5.  Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No fever or recent general malaise.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies any heart problems.  No orthopnea.  No palpitations.  No syncopal episodes.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS:  Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL:  Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS:  Blood pressure of 105/55, pulse is 90.  He is afebrile.  O2 saturation is 95% on room air.,HEAD AND NECK:  Face symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  The left knee is in closed dressing.  The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1.  Polyarthritis, status post left total knee replacement.  The patient tolerated the procedure well.,2.  Acromegaly, status post pituitary resection.  Continue supplemental hormones.,3.  Borderline hypertension, blood pressure is under control with monitoring.,4.  Deep venous thrombosis prophylaxis as per surgeon.,5.  Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.",Orthopedic Consult,Orthopedic,
Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion.,"PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.",Salpingooophorectomy - Laparoscopic,Obstetrics / Gynecology,
"Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.","PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.",Laparoscopic Hysterectomy,Obstetrics / Gynecology,"obstetrics / gynecology, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,"
A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,"HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.",Atrial Flutter - Progress Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter,"
"Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.","PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.",Laparoscopic Adrenalectomy,Cardiovascular / Pulmonary,
Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia.,"PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.",Adenoidectomy & Tonsillectomy & Lingual Frenulectomy,ENT - Otolaryngology,"ent - otolaryngology, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery"
Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.,"CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.",Conformal Simulation,Hematology - Oncology,"hematology - oncology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Holter Monitor Report,"INTERPRETATION:,1.  Predominant rhythm is normal sinus rhythm.,2.  No supraventricular arrhythmia.,3.  Frequent premature ventricular contractions.,4.  Trigemini and couplets.,5.  No high-grade atrial ventricular block was noted.,6.  Diary was not kept.,IMPRESSION:,  Frequent premature atrial contractions, couplets, and trigemini.,",Holter Monitor Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial,"
Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to ""pop into place.""  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , 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:  Blood pressure 130/70",Feet & Hand Cramping,Neurology,
A 37 year-old female with twin pregnancy with threatened premature labor.,"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",Ultrasound OB - 3,Obstetrics / Gynecology,
MRI head without contrast.,"EXAM:,  MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:,  Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction.  There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan.  This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  No abnormal mass effect is identified.  There are no findings to suggest active hydrocephalus.  No abnormal extra-axial collection is identified.  There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation.  The region of the pituitary/optic chiasm grossly appears normal.  The mastoids and paranasal sinuses are clear.,IMPRESSION:,1.  No definite acute findings identified involving the brain.,2.  There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  Moderate to moderately advanced atrophy.",MRI Head - 1,Neurology,"neurology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic"
Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",Thyroid Mass Consult,Pediatrics - Neonatal,
Echocardiogram and Doppler,"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,",2-D Echocardiogram - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve"
"CT head without contrast.  Assaulted, positive loss of consciousness, rule out bleed.  CT examination of the head was performed without intravenous contrast administration.","EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration.  There are no comparison studies.,FINDINGS:  ,There are no abnormal extraaxial fluid collections.  There is no midline shift or mass effect.  Ventricular system demonstrates no dilatation.  There is no evidence of acute intracranial hemorrhage.  The calvarium is intact.  There is a laceration in the left parietal region of the scalp without underlying calvarial fractures.  The mastoid air cells are clear.,IMPRESSION:  ,No acute intracranial process.",CT Head - 4,Neurology,"neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast,"
DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.,"PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.",Pacemaker - DDDR,Cardiovascular / Pulmonary,
"A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.","CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to ""borderline labs.""  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:",Infantile Spasms,Pediatrics - Neonatal,
"Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.","CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.",Mantle Cell Lymphoma - Consult,Hematology - Oncology,
Patient with a history of ischemic cardiac disease and hypercholesterolemia.,"HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.",Ischemic Cardiac Disease - Progress Note,Cardiovascular / Pulmonary,
The patient comes in today because of feeling lightheaded and difficulty keeping his balance.,"HISTORY OF PRESENT ILLNESS:  ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance.  He denies this as a spinning sensation that he had had in the past with vertigo.  He just describes as feeling very lightheaded.  It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position.  It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over.  Lorazepam did not help this sensation.  His blood pressure has been up lately and his dose of metoprolol was increased.  They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form.  Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56.  Standing up blood pressure was 160/80 with a pulse rate of 56.  His general exam and neurological exam were detailed on our H&P form.  Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN:  ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past.  He states this is more of a lightheaded type feeling.  He did have a mild blood pressure drop here in the office.  We are also concerned that bradycardia might be contributing to his feeling of lightheadedness.  We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.",Lightheadedness,Neurology,"neurology, lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness,"
"EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.","PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.",EGD & Colonoscopy,Gastroenterology,"gastroenterology, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,"
Invasive carcinoma of left breast. Left modified radical mastectomy.,"PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.",Radical Mastectomy,Hematology - Oncology,"hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy"
MRI Head W&WO Contrast.,"EXAM:,  MRI Head W&WO Contrast.,REASON FOR EXAM:,  Dyspnea.,COMPARISON:,  None. ,TECHNIQUE:,  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.,IMPRESSION:,1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  ,2.  No evidence for acute infarction. ,3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4.  Diffuse cortical volume loss, consistent with patient's age. ,5.  Preliminary report was issued at the time of dictation.  ,",MRI Head,Neurology,"neurology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri"
"Stage IIA right breast cancer.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.","CHIEF COMPLAINT:,  Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS:  ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer.  She noticed a lump in the breast in November of 2007.  A mammogram was obtained dated 01/28/08, which showed a mass in the right breast.  On 02/10/08, she underwent an ultrasound-guided biopsy.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.  On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy.  The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative.  Therefore it was a T2, N0, M0 stage IIA breast cancer.  Of note, at that time she was taking hormone replacement therapy and that was stopped.  She underwent radiation treatment ending in May 2008.  She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara.  She also did not tolerate the Femara and I changed it to tamoxifen.  She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy.  She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen.  When I saw her on 04/28/10, she was really doing quite well with tamoxifen.  She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself.  She is not going take to any further tamoxifen.,Overall, she is feeling well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS:,  Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.,ALLERGIES:,  Sulfa, Betadine, and IV contrast.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Asthma.,2.  Hypertension.,3.  GERD.,4.  Eczema.,5.  Status post three cesarean sections.,6.  Status post a hysterectomy in 1981 for fibroids.  They also removed one ovary.,7.  Status post a cholecystectomy in 1993.,8.  She has a history of a positive TB test.,9.  She is status post repair of ventral hernia in November 2008.,SOCIAL HISTORY: , She has no tobacco use.  Only occasional alcohol use.  She has no illicit drug use.  She has two grown children.  She is married.  She works as a social worker dealing with adult abuse and neglect issues.  Her husband is a high school chemistry teacher.,FAMILY HISTORY:  ,Her father had prostate cancer.  Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.,PHYSICAL EXAM:,VIT:",Breast Cancer Followup - 1,Hematology - Oncology,
A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.,"EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.",MRI Shoulder - 2,Orthopedic,"orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior"
Revision and in situ pinning of the right hip.,"PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL:  ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis.  She underwent in situ pinning.  The patient on followup; however, noted to have intraarticular protrusion of her screw.  This was not noted intraoperatively on previous fluoroscopic views.  Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one.  Risks and benefits of surgery were discussed.  Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage.  All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A small bump was placed underneath her right buttock.  The right upper thigh was then prepped and draped in standard surgical fashion.  The upper aspect of the incision was reincised.  The dissection was carried down to the crew, which was easily found.  A guidewire was placed inside the screw with subsequent removal of the previous screw.  The previous screw measured 65 mm.  A 60 mm screw was then placed under direct visualization with fluoroscopy.  The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion.  The guidewire was removed.  The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat.  The skin was closed with 4-0 Monocryl.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape.  The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery.  She should continue toe touch weightbearing on her leg.  The wound may be wet in approximately 5 days.  The patient should follow up in clinic in about 10 days.  The patient is given Vicodin for pain.  Intraoperative findings were relayed to the mother.",Pinning - Hip,Orthopedic,"orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw,"
CT Abdomen and Pelvis with contrast,"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.",CT Abdomen & Pelvis - 1,Nephrology,"nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct"
"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.","CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",Reactive Airway Disease,Pediatrics - Neonatal,
"Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.","PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.",Bunionectomy & Arthrodesis,Orthopedic,
"Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.","Heart Catheterization, Ventriculography, & Angiography",Cardiovascular / Pulmonary,
"Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.  Partial medial meniscectomy.  Partial chondroplasty of patella.  Lateral retinacular release.  Open medial plication as well of the right knee.","PREOPERATIVE DIAGNOSES:,1.  Torn anterior cruciate ligament, right knee.,2.  Patellofemoral instability, right knee.,3.  Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1.  Complete tear anterior cruciate ligament, right knee.,2.  Complex tear of the posterior horn lateral meniscus.,3.  Tear of posterior horn medial meniscus.,4.  Patellofemoral instability.,5.  Chondromalacia patella.,PROCEDURES PERFORMED:,1.  Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2.  Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3.  Partial medial meniscectomy.,4.  Partial chondroplasty of patella.,5.  Lateral retinacular release.,6.  Open medial plication as well of the right knee.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,TOURNIQUET TIME:,  130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint.  The patella was noted to be situated laterally past the lateral femoral condyle.  There was a tear to the posterior horn of the medial meniscus within the white zone.  There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus.  There was a complete tear of the anterior cruciate ligament.  The posterior cruciate ligament appeared intact.  Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August.  She was diagnosed per MRI.  An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear.  She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations.  She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint.  All risks and benefits of surgery were discussed with her at length.  She was in agreement with the treatment plan.,PROCEDURE:  ,On 09/11/03, she was taken to the operating room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthetic was applied by the Anesthesiology Department.  Tourniquet was placed on the proximal thigh and it was then placed in a knee holder.  She was sterilely prepped and draped in the usual fashion.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  Longitudinal incision was made just medial to the tibial tubercle.  The subcutaneous tissue was carefully dissected.  Hemostasis was controlled with electrocautery.  The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction.  They were taken on the back table.  The soft tissue debris was removed from the tendons.  The ends of the tendons were sewn together using #5 Tycron whip type sutures.  The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table.  Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee.  The knee was inflated with saline solution and operative pictures were obtained.  The above findings were noted.  A second port site was initiated in the inferomedial parapatellar region.  Through this, a probe was placed.  Tear in the posterior horn medial meniscus was identified.  It was resected using a meniscal resector.  It was then further contoured using arthroscopic shaver.  Attention was then taken to the lateral compartment.  A partial meniscectomy was performed using the resector and the shaver.  The posterior periphery of the lateral meniscus was also noticed to be unstable.  A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon.  There was noted to be excellent fixation.  The shaver was then taken into the intrachondral notch.  First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint.  Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle.  Next, a tibial guide was placed through the anterior medial portal.  A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament.  This tibial tunnel was then drilled using 8 mm cannulated drill.  Next, an over-the-top guide was then placed at approximately the 11:30 position.  A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm.  Next the U shape guide was placed through tibial tunnel into the femur.  A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur.  It was then pulled out through the tibial tunnel using the You-shaped guide.  The tendon was then placed around the wire.  The wire was pulled back up through the tibial into the femoral tunnel.  A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons.  Attention was then pulled through the tibial tunnel.  The knee was cycled approximately 20 times.  A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft.  There was noted definite fixation of the graft.  There was no evidence of impingement either in full flexion or full extension.  The knee was copiously irrigated and it was then suctioned dry.  A longitudinal incision was made just medial to the patellofemoral joint.  Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision.  Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication.  The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture.  The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch.  She was placed in a DonJoy knee immobilizer.  The tourniquet was deflated.  It was noted the lower extremity was warm and pink with good capillary refill.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient is guarded.  She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension.  She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal.  She will require one to two more physical therapy to help regain motion and strength to the lower extremity.",Ligament Reconstruction & Meniscus Repair,Orthopedic,
Thoracentesis.  Left pleural effusion.  Left hemothorax.,"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,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest,"
"Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2.  Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.","PREOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES:  ,1.  Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2.  Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2.  Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3.  Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA:  ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7.  Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen.  This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam.  Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7.  These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size.  The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition.  At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  There were no intraoperative complications of any type.",Anterior Cervical Discectomy & Fusion - 5,Neurosurgery,"neurosurgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy"
"MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.","CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.",MRI L-Spine - Subarachnoid Seeding,Orthopedic,"orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,"
"Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.","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 - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal"
"Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.","PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.",Laminectomy & Facetectomy,Neurosurgery,
"Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.","PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.",Tarsectomy,Orthopedic,"orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone"
"Patellar tendon and medial and lateral retinaculum repair, right knee.   Patellar tendon retinaculum ruptures, right knee.","PREOPERATIVE DIAGNOSIS:  , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS:  ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital.  This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention.  He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam.  Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum.  Minimal cartilaginous pieces were at the patellar tendon.  He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department.  A thigh high tourniquet was placed.  He is prepped and draped in the usual sterile manner.  Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes.  Straight incision is carried down through skin and subcutaneous tissue anteriorly.  Hemostasis was controlled via electrocoagulation.  Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape.  The inferior pole was freshened up.  Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer.  This was tied over the bony bridge superiorly.  There was excellent reduction of the tendon to the patella.  Interrupted running #1-Vicryl suture was utilized for over silk.  A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum.  There was excellent repair.  Copious irrigation was carried out.  Tourniquet was dropped and hemostasis controlled via electrocoagulation.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin.  Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing.  Digits were warm and no brawny pulses present at the end of the case.  The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion.  He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.",Patellar Tendon & Retinaculum Repair,Orthopedic,"orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum"
Nephrology Consultation - Patient with renal failure.,"REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:",Nephrology Consultation - 2,Nephrology,
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,"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.",VVIR Permanent Pacemaker Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads,"
Left axillary lymph node excisional biopsy.  Left axillary adenopathy.,"PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.",Lymph Node Excisional Biopsy,Hematology - Oncology,"hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy"
Transesophageal echocardiogram for aortic stenosis.  Normal left ventricular size and function.  Benign Doppler flow pattern.   Doppler study essentially benign.  Aorta essentially benign.  Atrial septum intact.  Study was negative.,"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,",Transesophageal Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves"
"The patient is 14 months old, comes in with a chief complaint of difficulty breathing.","HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",Difficulty Breathing - ER Visit,Pediatrics - Neonatal,
"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.","PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",Facetectomy & Foraminotomy,Orthopedic,
"Subxiphoid pericardiotomy.  Symptomatic pericardial effusion.  The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.","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.",Subxiphoid Pericardiotomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial"
Psychiatric Consultation of patient with altered mental status.,"REASON FOR CONSULT:,  Altered mental status.,HPI:,  The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month.  Last night, he became confused and he eloped from the unit.  When he was found, he became combative.  This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly.  There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  He reports feeling fine currently, denying any complaints.  The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment.  She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety.  He also denies any hallucinations or delusions.  He endorses problems with insomnia.  At home, he takes temazepam.  His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:,  He denies any prior psychiatric treatment or intervention.  However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily.  He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1.  Heart transplant in 1997.,2.  History of abdominal aortic aneurysm repair.,3.  Diverticulitis.,4.  Cholecystectomy.,5.  Benign prostatic hypertrophy.,ALLERGIES:,  MORPHINE AND DEMEROL.,MEDICATIONS:,1.  Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2.  Imodium 2 mg p.o. p.r.n., loose stool.,3.  Calcium carbonate with vitamin D 500 mg b.i.d.,4.  Prednisone 5 mg p.o. daily.,5.  Bactrim DS Monday, Wednesday, and Friday.,6.  Flomax 0.4 mg p.o. daily.,7.  Robitussin 5 mL every 6 hours as needed for cough.,8.  Rapamune 2 mg p.o. daily.,9.  Zoloft 50 mg p.o. daily.,10.  B vitamin complex daily.,11.  Colace 100 mg b.i.d.,12.  Lipitor 20 mg p.o. q.h.s.,13.  Plavix 75 mg p.o. daily.,14.  Aricept 5 mg p.o. daily.,15.  Pepcid 20 mg p.o. daily.,16.  Norvasc 5 mg p.o. daily.,17.  Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:,  The patient is a retired paster and missionary to Mexico.  He is still actively involved in his church.  He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:,  He is an average-sized white male, casually dressed, with wife and son at bedside.  He is pleasant and cooperative with good eye contact.  He presents with paucity of speech content; however, with regular rate and rhythm.  He is tremulous which is worse with posturing also some increased motor tone noted.  There is no evidence of psychomotor agitation or retardation.  His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  His thoughts are circumstantial but logical.  He defers most of his responses to his wife.  There is no evidence of suicidal or homicidal ideations.  No presence of paranoid or bizarre delusions.  He denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  His attention is fair and his concentration impaired.  He is oriented x3 and his insight is fair.  On mini-mental status examination, he has scored 22 out of 30.  He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  On category fluency, he was able to name 17 animals in one minute.  He was unable to draw clock showing 2 minutes after 10.  His judgment seems limited.,LABORATORY DATA:,  Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:,  MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1.  Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2.  Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3.  Depressive disorder, not otherwise specified.",Psych Consult - Altered Mental Status,Psychiatry / Psychology,
Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability,"COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:,  The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability.  He is a 43-year-old married, white male who came unaccompanied to the evaluation.  He drove himself suggesting that he drives regularly.  He reportedly has been on Disability since around 2002.  He was a good historian, freely offering information.  He was dressed and groomed casually, yet neat and appropriate in appearance.  He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning.  No censorship of data was indicated.  ,PRESENT PROBLEMS:,  The claimant described his recent problems as, ""serious depression.  Very hard to concentrate.  Very short tempered.  Usually distracted."" ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago.  He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because ""I had a breakdown and ended up in the hospital.  They said that I wasn't reliable enough and laid me off.""  Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed.  ,The claimant has had significant emotional problems since around 1997.  He was first hospitalized in that year and has been hospitalized five more times since then.  The last hospitalization was last month in Atlanta, Georgia.  He has tried to overdose in the past as well as cut his wrist.  He even had to undergo electroconvulsive therapy in 2001, because of depression.  He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident.  Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d.  He is not involved in outpatient therapy.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  The claimant indicated that he graduated from high school in regular classes.  He did have to repeat the kindergarten because he was too young.  He worked for about 10 years at a company in Massachusetts.  He was not advancing on that job and therefore quit.  He has had three subsequent jobs and a number of emotional problems since.  He indicated usually getting along with others but stated, ""I had trouble taking direction from someone younger than me.  I resent getting nagged at.  I'd get angry or just seethe.""  He has been let go from his last two jobs because of emotional issues.  ,The claimant was married the first time for five years.  He has no children.  He now lives at home with his wife., ,The claimant denied any legal problems.  He suggested that his mother had bipolar disorder.  He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs.  He stopped drinking in 1997.  Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:,  The claimant described his typical day as follows, ""I usually get up about 7:00 to 7:30.  Have breakfast.  Take a shower about 8:30.  Do errands.  Me and my wife are out of the house by 9:00.  Check e-mail at the library.  I like the computer.  We have lunch 11:30 or 12:00.  Do errands or watch talk shows or I'll read.  I love to read.  Around 5:00 to 5:30, have supper.  Watch the news, game shows.  In bed by 10:00.""  He will help with vacuuming, doing the dishes or yard work.  His wife does most of the house cleaning.  He does no cooking.  He and his wife get out every day usually for three or four hours.  He has a neighbor next door that he will see twice a week.  He used to go to the gym but has not been in a few weeks.  No other family contact was described and he does not go to church.  When asked what he enjoys he stated, ""read, use my computer or go ride my bike."", ,MENTAL STATUS EVALUATION:,  On interview, the claimant looked his stated age of 43 years.  He was tall in stature and thin in weight.  He was neat and clean in appearance.  Posture was somewhat tense but psychomotor activity was not remarkable.  Eye contact was fleeting with fair social skills evident.  Facial expression was tense and affect was restricted with little animation noted.  General mood appeared dysphoric.  Speech was clear, coherent, logical, goal-directed and relevant.  He was cooperative in attitude toward the examiner.  He described his recent mood as, ""cloudy, gray because we've got a lot of personal problems right now.  I'm frustrated because I don't know where things are going.""  He described some problems with falling asleep and staying asleep at night as well as decreased energy level.  He denied appetite disturbance.  He has lost interest in some activities suggesting mild anhedonia.  He has trouble with attention and concentration stating, ""I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder.""  He has thoughts of suicide about once or twice a week and has often fled situations in the past.  He stated, ""I try to keep myself from running away.""  He denied any plan or intent for suicide.  He suggested significant anxiety problems as well.  He stated, ""I'm dealing with pedophilia.  I try to time it so that I don't go to a store with lots of people around.  If there is people I get real edgy, heart pounds, shortness of breath.  A lot of chest discomfort.""  He has these panic symptoms quite regularly and they have occurred ever since 1997.  That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail.  No phobic processes were suggested.  No psychotic symptoms were revealed.  He denied hallucinations and no delusional material was elicited.  Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres.  He evidenced adequate memory for both recent and remote events.  He was able to recall 3 of 3 words after a 1 minute and 10 minute delay.  Fair sustained attention and concentration skills were shown.  He was able to spell a word backward and performed a serial 7 subtraction task affectively.  Basic calculation skills were intact and no language-based dysfunction was noted.  Social judgment was also intact as he gave a good response to finding a wallet in the street, ""find who the owner was, bring it to the police station or contact the person,"" and to seeing smoke in a theater, ""Get a hold of staff so they could evacuate.""  Adequate conceptual abilities was shown with similarity comparisons.  Somewhat limited abstraction was shown with proverb interpretation, glass houses, ""don't do anything you're not supposed to do.""  Premorbid intellect is estimated to be at least in the average range.  Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I:  Major Depression, recurrent, moderate.  Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:,  Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities.  He continues to show significant problems with depression and anxiety.  He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations.  He relies on his wife to take care of most all household task.  He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:,  The claimant was strongly encouraged to get some additional help for his emotional problems.  He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.",Mental Status Evaluation,Psychiatry / Psychology,
Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.,"PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.",Ganglion Excision,Orthopedic,"orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion"
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.,"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.",Air Under Diaphragm - Consult,Gastroenterology,
Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",Anterior Cervical Discectomy & Fusion - 4,Neurosurgery,
"Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.","PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.",Anterior Cervical Discectomy & Interbody Fusion,Orthopedic,
"Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.","CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.",Posttransplant Lymphoproliferative Disorder,Hematology - Oncology,"hematology - oncology, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative,"
The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,"IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.",Psych Consult - Psychosis - 2,Psychiatry / Psychology,
Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,"PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.",Cemented Hemiarthroplasty & Biopsy,Orthopedic,
Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass.,"PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.",Mediastinal Mass Resection,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,"
"Arthroscopy of the left knee with medial meniscoplasty.  Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.","PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:,  Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA:  ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology.  The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded.  Tourniquet was placed around the left upper thigh.  The limb was then prepped and draped in usual sterile fashion.  Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed.  Patellofemoral joint showed frequent chondromalacia.  Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus.  The medial femoral condyle and medial tibial plateau were unaffected.  Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus.  The femoral condyle and tibial plateau were all stable to probing.  Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors.  A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry.  20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals.  A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose.  The patient was then transferred to the recovery room in stable condition.",Knee Arthroscopy & Medial Meniscoplasty,Orthopedic,"orthopedic, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial"
Desires permanent sterilization.  Laparoscopic bilateral tubal occlusion with Hulka clips.,"PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:  ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  There were no adnexal masses appreciated.  The vulva and perineum appeared normal.  Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  There was a functional cyst on the left ovary.  There was filmy adhesion in the left pelvic sidewall.  There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  The liver was visualized and appeared normal.  The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization.  She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  She was then prepped and draped and placed in the dorsal lithotomy position.  A bimanual exam was performed and the above findings were noted.  Prior to beginning the procedure, her bladder was drained with a red Robinson catheter.  A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  The cervix was dilated so that the uterine elevator could be placed.  Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  The Veress needle was then inserted and using sterile saline ______ the pelvic cavity.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  A second Hulka clip was then placed across the entire diameter just proximal to this.  There was good hemostasis at the fallopian tube.  The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  A second Hulka clip was placed just distal to this again across the entire diameter.  Good hemostasis was obtained.  At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl.  The suprapubic incision was then closed with Steri-Strips.  The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  The patient tolerated that procedure well.  The sponge, lap, and needle counts were correct x2.  She will follow up postoperatively for followup care.",Bilateral Tubal Occlusion - Laparoscopic,Obstetrics / Gynecology,"obstetrics / gynecology, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips,"
Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.,"DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.",Polycythemia Vera Followup,Hematology - Oncology,"hematology - oncology, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis,"
The patient admitted with palpitations and presyncope.,"HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,",Consult - Palpitations & Presyncope,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart"
Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.  Patient with a 5.5-cm diameter nonfunctioning mass in his right adrenal.,"PREOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1.  Adrenal mass, right sided.,2.  Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA:  ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal.  Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required.  Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION:  ,In the right flank-up position, table was flexed.  He had a Foley catheter in place.  Incision was made from just above the umbilicus, about 5.5 cm in diameter.  The umbilical hernia was taken down.  An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin.  A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt.  The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly.  The vena cava was identified.  The main renal vein was identified.  Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided.  Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie.  The harmonic scalpel was utilized superiorly and laterally.  Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided.  Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down.  The edges were freshened up.  Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well.  All sponge and instrument counts were correct.  Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition.",Adrenalectomy & Umbilical Hernia Repair,Hematology - Oncology,"hematology - oncology, adrenalectomy, laparoscopic hand-assisted, umbilical hernia repair, vena cava, renal vein, hernia repair, laparoscopic, umbilical, hernia,"
Psychiatric consultation for management of pain medications.,"REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.",Psych Consult - Pain Meds,Psychiatry / Psychology,
"Emergent subxiphoid pericardial window, transesophageal echocardiogram.","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.",Subxiphoid Pericardial Window,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic"
Dobutrex stress test for abnormal EKG,"INDICATIONS:,",Stress Test Dobutrex,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress,"
Colonoscopy to evaluate prior history of neoplastic polyps.,"PREOPERATIVE DIAGNOSIS:,  Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:,  Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:,  Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction.  She was then given 25 mg of Phenergan IV.  Following this, her headache and nausea completely resolved.  She was then given a total of 7.5 mg of Versed with adequate sedation.  Rectal exam revealed no external lesions.  Digital exam revealed no mass.,REPORTED PROCEDURE:,  The P160 colonoscope was used.  The scope was placed in the rectal ampulla and advanced to the cecum.  Navigation through the sigmoid colon was difficult.  Beginning at 30 cm was a very tight bend.  With gentle maneuvering, the scope passed through and then entered the cecum.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  The sigmoid colon was likewise normal.  There were five very small (punctate) polyps in the rectum.  One was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  There was no specimen because the polyps were so small.  The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Five small polyps as described, all fulgurated.,2.  Otherwise unremarkable colonoscopy.",Colonoscopy - 3,Gastroenterology,"gastroenterology, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope"
Rhabdomyosarcoma of the left orbit.  Left subclavian vein MediPort placement.  Needs chemotherapy.,"PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.",MediPort Placement,Hematology - Oncology,"hematology - oncology, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport,"
Nephrology office visit for followup of CKD.,"HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,",Nephrology Office Visit - 3,Nephrology,
Blepharoplasty with direct brow repair.,"PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  Visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  These field losses resolved with upper eyelid taping which simulates the expected surgical correction.  Photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  The risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,DESCRIPTION OF PROCEDURE:, On the day of surgery, the surgical site and procedure were verified by the physician with the patient.  An informed consent was signed and witnessed.  EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  Two drops of topical proparacaine eye drops were placed on the ocular surface.  The skin was cleaned with alcohol prep pads.  The patient received 3 to 4 mL of 2% Lidocaine with epinephrine and 0.5% Marcaine mixture to each upper lid.  5 to 6 mL of local were also given to the brow region along the entire length.  Pressure was applied over each site for 5 minutes.  The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  The contour of the outline was created to provide a greater temporal lift.  Care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  Using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  The dimensions of the redundant tissue measured * horizontally and * vertically.  The redundant tissue was removed sharply with Westcott scissors.  Hemostasis was maintained with hand held cautery and/or electrocautery.  The closure was carried out in multiple layers.  The deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  The intermediate layer was closed with 5-0 Vicryl similarly.  The skin was closed with 6-0 nylon in a running lock fashion.  Iced saline gauze pads were placed over the incision sites.  This completed the brow repair portion of the case.,Using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  These lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  The desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  This tissue was outlined with a surgical marking pen.  Care was taken to avoid excessive skin removal near the brow region.  A surgical ruler was used to ensure symmetry.  The skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  This layer was removed with Westcott scissors.,Hemostasis was achieved with high-temp hand held pen cautery.  The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  Care was taken to not disturb the levator aponeurosis.  A symmetric amount of fat was removed from each side.  Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  Saline gauze and cold packs were placed over the upper lids.  The patient was taken from the surgical suite in good condition.,DISCHARGE:,  In the recovery area the results of surgery were discussed with the patient and their family.  Specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  Instructions on antibiotic ointment use were reviewed.  The incision sites were checked prior to release.  The patient was released to home with a driver after vital signs were deemed stable.",Blepharoplasty - Direct Brow Repair,Ophthalmology,"ophthalmology, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision sites, incision, brow, ptosis, surgical"
"Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.","PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain.  The patient was found to have cholelithiasis on last admission.  He was being worked up for this including cardiac clearance.  However, in the interim, he returned again with another episode of same pain.  The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction.  Because of these, laparoscopic cholecystectomy was advised with cholangiogram.  Possibility of open laparotomy and open procedure was also explained to the patient.  The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia.  The entire abdomen was prepped and draped.  A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia.  The patient has a rather long torso.  Fascia was opened vertically and stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2.  Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area.  The patient was placed in reverse Trendelenburg and rotated to the left.  An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Slowly, the dissection was carried out in the right subhepatic area.  Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver.  Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation.  The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick.  After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy.  The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered.  A Bookwalter retractor was put in place.  The dissection was then carried out on the undersurface of the liver.  Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it.  Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size.  The duodenum was kocherized.  The gallbladder was partly intrahepatic.  Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem.  The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was.  Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short.  Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy.  This showed a rounded density at the lower end of the bile duct consistent with the stone.  At this time, a decision was made to proceed with common duct exploration.  The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out.  After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct.  So, it was about a 1-cm size stone, which was removed.  Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously.  No further stones were obtained.  The catheter went easily into the duodenum through the ampulla of Vater.  At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree.  However, a stone was found distally still floating around.  This was removed with stone forceps.  The bile ducts were irrigated again.  No further stones were removed.  A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure.  A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area.  Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area.  I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct.  The bile duct lumen was widely open.  T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time.  The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site.  The T-tube was brought out through the middle 5-mm port site, which was just above the incision.  Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia.  Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers.  Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control.  The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin.  Sterile dressing was applied, and the patient transferred to recovery room in stable condition.","Laparoscopy, Laparotomy, & Cholecystectomy",Gastroenterology,"gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder"
"Paracentesis.  A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.","PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:,  Paracentesis.,DESCRIPTION OF PROCEDURE:  ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  At the present time, the patient is under radiation treatment.  Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  The cytology of the fluid was negative and the culture was also negative.  Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  Therefore, I called the patient home and she came to the emergency department where the service was provided.  At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  Unfortunately, the catheter was open.  I did not have a drainage system at that time.  So, I withdrew directly with a syringe 700 mL of clear fluid.  The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  She was given an appointment to see me in the office next Monday, which is three days from now.",Paracentesis,Gastroenterology,"gastroenterology, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis,"
Primary low-transverse cesarean section.,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.",Low-Transverse C-Section,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy at term, arrest of dilation, cephalic presentation, low transverse cesarean section, cesarean section, rectus muscles, intrauterine,"
"Anterior spine fusion from T11-L3.  Posterior spine fusion from T3-L5.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.","PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES:  ,1.  Anterior spine fusion from T11-L3.,2.  Posterior spine fusion from T3-L5.,3.  Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis.  This was found to be moderately corrected.  Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis.  He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression.  Risks and benefits were discussed at length with the family over many visits.  They wished to proceed.,PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in the supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  Appropriate lines were then placed.  He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up.  An oblique incision was then made over the flank overlying the 10th rib.  Underlying soft tissues were incised down at the skin incision.  The rib was then identified and subperiosteal dissection was performed.  The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally.  This allowed for entry into the pleural space.  The lung was then packed superiorly with wet lap.  The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies.  This required cauterization of the segmental vessels.  Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed.  These were performed from T11-L3.  This was over 5 levels.  Disks and endplates were then removed.  Once this was performed, morcellized rib autograft was placed into the spaces.  The table had been previously bent to allow for easier access of the spine.  This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity.  The ribs were held together with #1 Vicryl sutures.  Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well.  Skin was closed as needed with running #4-0 Monocryl.  This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position.  The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5.  The underlying soft tissues were incised down at the skin incision.  Electrocautery was then used to maintain hemostasis.  The spinous processes were then identified and the overlying apophyses were split.  This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes.  Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine.  These were placed at L4 and L5.  The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum.  This was done using a rongeur as well as a Kerrison rongeur.  Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed.  These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned.  This was secured initially at the screws distally on both the left and right side.  The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine.  This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin.  This was done using pulsed lavage.,The wound was then closed in layers.  The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed.  The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape.  The patient was awakened from anesthesia and taken to the intensive care unit in stable condition.  All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.",Spine Fusion,Orthopedic,"orthopedic, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft,"
"This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.","REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly ""no- no"" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.",Essential Tremor & Torticollis,Neurology,"neurology, clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,"
Stress test with Bruce protocol due to chest pain.,"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.,",Stress Test Bruce Protocol,Cardiovascular / Pulmonary,
"CT abdomen without contrast and pelvis without contrast, reconstruction.","EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE:  ,Noncontrast CT abdomen and pelvis.  An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal.  There is a moderate amount of stool throughout the colon.  There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process.  Examination of the extreme lung bases appear clear, no pleural effusions.  The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast.  There is a small hiatal hernia.  There is no intrarenal stone or evidence of obstruction bilaterally.  There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast.  This can be correlated with a followup ultrasound if necessary.  The gallbladder has been resected.  There is no abdominal free fluid or pathologic adenopathy.  There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy.  There are surgical clips present.  There is a tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder.  If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.  The report was faxed upon dictation.",CT Abdomen & Pelvis - 5,Nephrology,"nephrology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,"
The patient has been suffering from intractable back and leg pain.,"Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,",Consult - Back & Leg Pain,Orthopedic,"orthopedic, multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar"
"Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs","CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.",Orthopedic Consult - 1,Orthopedic,
Psychiatric Consultation of patient with anxiety.,"REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  ""I felt anxious yesterday."",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with ""syncopal episodes.""  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.",Psych Consult - Anxiety,Psychiatry / Psychology,
"Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.","CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.",Blood per Rectum,Gastroenterology,
Laparoscopic cholecystectomy.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,"PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,PROCEDURE:  ,After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 3 other trocars were placed.  The first was a 10/11 mm trocar in the upper midline position.  The second was a 5 mm trocar placed in the anterior iliac spine.  The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left.  The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The cystic artery was found medially and slightly posterior to the cystic duct.  It was carefully dissected free from its surrounding tissues.  A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  The artery was divided between the clips.  The 2 midline port sites were injected with 5% Marcaine.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula.  As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  The neck of the gallbladder was removed from the abdomen.  Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture.  All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  Dressings were applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",Laparoscopic Cholecystectomy - 9,Gastroenterology,"gastroenterology, langer's lines, laparoscope, cystic duct, cystic artery, laparoscopic cholecystectomy, midline cannula, infraumbilical, tonsil, cholecystectomy, fascia, abdomen, trocars, cannula, laparoscopic, gallbladder,"
Encephalopathy related to normal-pressure hydrocephalus.,"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,",Encephalopathy  - Rehab Consult,Neurology,
"Missed abortion.  Suction, dilation, and curettage.","PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.","Suction, Dilation, & Curettage",Obstetrics / Gynecology,"obstetrics / gynecology, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine"
Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.,"CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.",Leaking Nephrostomy Tube,Nephrology,"nephrology, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes,"
Psychosocial Evaluation of patient before kidney transplant.,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",Psychosocial Eval for Kidney Transplant,Psychiatry / Psychology,
"Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy","EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,",Renal Ultrasound,Nephrology,"nephrology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal,"
Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,"CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.",CT Angiography - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,"
"CT abdomen and pelvis without contrast, stone protocol, reconstruction.","EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.",CT Abdomen & Pelvis - 4,Gastroenterology,"gastroenterology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,"
"A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.","REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.",Rectal Bleeding - Consult,Gastroenterology,
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.,"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.",Brain Tumor - Consult,Hematology - Oncology,"hematology - oncology, spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent"
Burr hole and insertion of external ventricular drain catheter.,"PREOPERATIVE DIAGNOSES:,  Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:,  Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped.  He was prepped with ChloraPrep and Betadine.  Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000.  He did receive antibiotics post procedure.  He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion.  A self-retaining retractor was placed.  Burr hole was drilled with the cranial twist drill.  The dura was punctured with a twist drill.  A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle.  The pressure was initially high.  The CSF was clear and colorless.  The CSF drainage rapidly tapered off because of the brain swelling.  With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull.  There was intermittent drainage of CSF after that.  The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss is minimal.  None replaced.",Ventricular Drain Catheter Insertion,Neurosurgery,"neurosurgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter,"
"Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.","ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.",Goldenhar Syndrome - Discharge Summary,Pediatrics - Neonatal,
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.,"REASON FOR CONSULTATION:,  Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  She last saw Dr. X in clinic towards the beginning of this month.  She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  She was last seen in clinic on 12/22/08 by Dr. Y.  At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  Her ANC was 0.5.  She was started on prophylactic Augmentin as well as Neupogen shots.  She has also had history of recurrent pleural effusions with the knee for thoracentesis.  She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath.  Her history is somewhat limited today as she is very tired and falls asleep readily.  Her history comes from herself but also from the review of the records.  Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  She specifically denied any fevers or chills.  However, she was complaining of chest pain.  She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  When she did cough, it was nonproductive.  While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes.  The chest x-ray described above showed a right lower lobe infiltrate.  A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  The findings were compatible with an indeterminate study for a pulmonary embolism.  Apparently, an ultrasound of the lower extremities was done and was negative for DVT.  There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox.  There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1.  Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO.  This has recurred over the last couple of months with metastatic disease.,2.  History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  She has had no recurrent disease.,3.  Renal cell carcinoma - She is status post nephrectomy.,4.  Hypertension.,5.  Anxiety disorder.,6.  Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  Ongoing tobacco use.,PAST SURGICAL HISTORY,1.  Recent and multiple thoracentesis as described above.,2.  Bilateral mastectomies.,3.  Multiple abdominal surgeries.,4.  Cholecystectomy.,5.  Remote right ankle fracture.,ALLERGIES:,  No known drug allergies.,MEDICATIONS: , At home,,1.  Atenolol 50 mg daily,2.  Ativan p.r.n.,3.  Clonidine 0.1 mg nightly.,4.  Compazine p.r.n.,5.  Dilaudid p.r.n.,6.  Gabapentin 300 mg p.o. t.i.d.,7.  K-Dur 20 mEq p.o. daily.,8.  Lasix unknown dose daily.,9.  Norvasc 5 mg daily.,10.  Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years.  She quit smoking about 6 weeks ago.  She occasionally has alcohol.  She is married and has 3 children.  She lives at home with her husband.  She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:,  Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  HEENT:  She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  CHEST:  Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  CVS:  She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations.  GI:  No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  GU:  No dysuria, burning with urination, kidney stones, and difficulty voiding.  MUSCULOSKELETAL:  No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  NEUROLOGIC:  She has been diffusely weak but no lateralizing loss of strength or feeling.  She has some chronic neuropathic pain and numbness as described above in the past medical history.  She is fatigued and tired today and falls asleep while talking but is easily arousable.  Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her T-max is 99.3.  Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL:  Somewhat fatigued appearing but in no acute distress.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without any erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No thyromegaly.  No thyroid nodules.,CHEST:  Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS:  Regular rate and rhythm.  No murmurs, gallops or rubs.  Normal S1 and S2.  No S3 or S4.,ABDOMEN:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No guarding or rebound.  No hepatosplenomegaly.  No masses.",Metastatic Ovarian Cancer - Consult,Hematology - Oncology,
Patient returns for his first followup after shunt surgery.,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",First Followup - Shunt Surgery,Neurology,
"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.","PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",Facetectomy & Foraminotomy,Neurosurgery,
"Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter.  Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.","PREOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,PROCEDURE PERFORMED:,1.  Insertion of a right brachial artery arterial catheter.,2.  Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis.  She was severely dehydrated and necessitated some fluid boluses.  The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  She required intubation and has been ventilator-dependent in the Intensive Care since that time.  The patient developed very high temperatures as well as leukocytosis.  Her lines required being changed.,PROCEDURE:,1.  RIGHT BRACHIAL ARTERIAL LINE:  ,The patient's right arm was prepped and draped in the usual sterile fashion.  There was a good brachial pulse palpated.  The artery was cannulated with the provided needle and the kit.  There was good arterial blood return noted immediately.  On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery.  The femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  We did not feel that the shorter catheter would provide enough length.  The catheter was connected to the system and flushed without difficulty.  A good waveform was noted.  The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2.  RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER:  ,The patient was prepped and draped in the usual sterile fashion.  1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  We roughed the needle down off the clavicle and directed it towards the sternal notch.  There was good venous return noted immediately.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein.  The needle was then removed.  A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  Next, the triple lumen catheter was inserted over the guidewire without difficulty.  The guidewire was removed.  All the ports aspirated and flushed without difficulty.  The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied.  The patient tolerated the above procedures well.  A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.",Triple Lumen Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle,"
MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.",MRI Brain & Cerebral Angiogram,Radiology,
"Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.","PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1.  Injection for myelogram.,2.  Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:,  Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:,  Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution.  The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  He denied any previous history of back pain or back surgeries.  Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  After an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,PROCEDURE DETAIL:  ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03.  After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table.  All of his bony prominences were well-padded.  At this time, a myelogram was then performed.  After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  The needle was localized to the level of L3-L4 region.  Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  At this time, approximately 10 cc of Conray injected into the thecal sac.  The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast.  The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left.  There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy.  At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  A long spinal needle was then inserted into region of surgery on the right.  The surgery was going to be on the left.  Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region.  At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  At this time, a Weitlaner was inserted.  Bovie cautery was used to obtain hemostasis.  We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  At this time, a Taylor retractor was then inserted and held there for retraction.  Suction as well as Bovie cautery was used to obtain hemostasis.  At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive.  We removed the extruded disc with further freeing up of the S1 nerve root.  A nerve root retractor was then placed.  Identification of disc space was then performed.  A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  A small pituitary was then inserted within the disc space and more disc material was freed and removed.  The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound.  We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  At this time, a small piece of Gelfoam was then used to cover the exposed nerve root.  We did not have any dural leaks during this case.  #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin.  Sterile dressings were then applied.  The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition.  At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.",Lumbar Laminectomy & Discectomy,Orthopedic,"orthopedic, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram"
Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.,"PREOPERATIVE DIAGNOSIS:,  Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation.  The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction.  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  Hemostasis was obtained with a bipolar cautery.  A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed.  The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  A similar procedure was performed exposing herniated portion of the nasal pocket.  Great care was taken to obtain perfect hemostasis with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  Careful hemostasis had been obtained on the upper lid areas.  The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  There was no diplopia, no ptosis, no ectropion.  Wounds were reexamined for hemostasis, and no hematomas were noted.  Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.",Bilateral Upper Lid Blepharoplasty,Ophthalmology,"ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis"
DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.,"PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.",Pacemaker - DDDR,Cardiovascular / Pulmonary,
"Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.","PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.","Heart Catheterization, Ventriculography, & Angiography - 5",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,"
"HCT: SAH, Contusion, Skull fracture","CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt ""dazed."" He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.","SAH, Contusion, Skull Fracture",Neurology,"neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture,"
Bilateral open Achilles lengthening with placement of short leg walking cast.,"PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia.  A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS:  ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME:  ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:,  The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year.  The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally.  He does not walk with a crouched gait but does toe walk.  Given his tightness, surgery versus observation was recommended to the family.  Family however wanted to correct his toe walking.  Surgery was then discussed.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems.  All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table  General anesthesia was then administered.  The patient received Ancef preoperatively.  The patient was then subsequently placed prone with all bony prominences padded.  Two bilateral nonsterile tourniquets were placed on each thigh.  Both extremities were then prepped and draped in a standard surgical fashion.  We turned our attention first towards the left side.  A planned incision of 1 cm medial to the Achilles tendon was marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Incision was then made and carried down through subcutaneous fat down to the tendon sheath.  Achilles tendon was identified and Z-lengthening was done with the medial distal half cut.  Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked.  This was trimmed to obtain an end-on-end repair with 0 Ethibond suture.  This was also oversewn.  Wound was then irrigated.  Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat.  The skin was closed using 4-0 Monocryl.  Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine.  It was then dressed with 4 x 4 and Webril.  Tourniquet was released at 30 minutes.  The same procedure was repeated on the right side with tourniquet time of 21 minutes.  While the patient was still prone, two short-leg walking casts were then placed.  The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN:  ,The patient will be discharged on the day of surgery.  He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks.  He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months.  The patient may or may not need physical therapy while his Achilles lengthenings are healing.  The patient is not to participate in any PE for at least 6 months.  The patient is given Tylenol No. 3 for pain.",Achilles Lengthening,Orthopedic,"orthopedic, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,"
Laparoscopic appendectomy.  The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.",Laparoscopic Appendectomy - 5,Gastroenterology,"gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix"
"Cataract, right eye.  Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.","PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:  ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA:  ,Topical.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,The patient was identified.  The operative eye was treated with tetracaine 1% topically in the preoperative holding area.  The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye.  The lashes were tapped using Steri-Strips to prevent blinking.  A lid speculum was placed to prevent lid closure.  Anesthesia was verified.  Then, a 3.5-mm groove was created with a diamond blade temporarily.  This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane.  A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat.  A paracentesis was made.  A round capsulorrhexis was performed.  The anterior capsular flap was removed.  Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique.  The irrigating-aspirating machine was used to clear residual cortex.  The Provisc was instilled.  An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified.  The viscoelastic was removed.  Intraocular lens remained well centered.  The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal.  The anterior chamber remained deep, and there was no wound leak.  The patient tolerated the procedure well.  The eye was dressed with Maxitrol ointment.  A tight patch and Fox shield were placed.  The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.",Phacoemulsification Of Cataract - 2,Ophthalmology,"ophthalmology, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular"
"This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure.","HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.",Pulmonary Edema - Consult,Cardiovascular / Pulmonary,
"Patient experienced a single episode of his vision decreasing.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale.","CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis.  He reports he experienced a single episode of his vision decreasing ""like it was compressed from the top down with a black sheet coming down"".  The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car.  He was able to pull the car over to the side of the road safely.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale and ashen during the episode.  He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable.  It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker.  He has had no further similar events.  He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis.  The question has arisen as to whether he should have a CT myelogram to further evaluate this process.  He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness.  He is extremely active and plays tennis at least three times a week.  He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain.  He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative.  A copy is in his clinic chart.,PAST MEDICAL HISTORY:  ,As above.  He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  He is retired from the social security administration x 20 years.  He travels a lot and is extremely active.  He does not smoke.  He consumes alcohol socially only.  He does not use illicit drugs.  He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago.  He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs:  BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds.  He denies any pain.,General:  This is a pleasant white male in no acute distress.,HEENT:  He is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  There is no sinus tenderness.,Neck:  Supple.,Chest:  Clear to auscultation.,Heart:  There are no bruits present.,Extremities:  Extremities are warm and dry.  Distal pulses are full.  There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  He is alert and oriented to person, place and time with good recent and long-term memory.  His language is fluent.  His attention and concentration are good.,CRANIAL NERVES:  Cranial nerves II through XII are intact.  VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR:  He has normal bulk and tone throughout.  There is no cogwheeling.  There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5.  Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY:  He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION:  There is no dysmetria or tremor noted.  His Romberg is negative.  Note that he cannot rise from the chair without using his arms.,GAIT:  Upon arising, he has a normal step, stride, and toe, heel.  He has difficulty with tandem and tends to fall to the left.,REFLEXES:  2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1.  TIA.  The character of his brief episode of visual loss is concerning for compromise of the posterior circulation.  Differential diagnoses include hypoperfusion, stenosis, and dissection.  He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system.  He has recently been started on Paxil by his primary care physician and this should be continued.  Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup.  The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2.  Lumbar stenosis.  His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability.  In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time.  Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1.  We will get a CT angiogram of the cerebral vessels.,2.  Continue Plavix.,3.  Obtain copies of the workup done at the outside hospital.,4.  We will follow the lumbar stenosis for the time being.  No further workup is planned.",TIA & Lumbar Stenosis,Neurology,
"Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.","EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.",Angiogram & StarClose Closure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral,"
Left distal medial hamstring release.,"PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia.  Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAIN:  ,None.,SPECIMENS:  ,None.,HISTORY AND PHYSICAL:  ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero.  The patient has diagnosis of autism as well.  The patient presented with bilateral knee flexion contractures, initially worse on right than left.  He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play.  The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed.  Risks and benefits of the surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures.  All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE:  ,The patient was taken to operating room and placed supine on operating table.  General anesthesia was administered.  The patient received Ancef preoperatively.  Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  A small 3 cm incision was made over the distal medial hamstring.  Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius.  The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl.  The wound was cleaned and dried and dressed with Steri-Strips.  The area was infiltrated with total 10 mL of 0.25% Marcaine.  The wound was then covered with Xeroform, 4 x 4s, and Bias.  Tourniquet was released at 15 minutes.  The patient was then placed in knee immobilizer.  The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace.  He will start physical therapy in another week or two.  The patient restricted from any PE for at least 6 week.  He may return to school on 01/04/2008.  He was given Vicodin for pain.",Hamstring Release,Orthopedic,"orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring,"
"Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.","PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.",OB/GYN Consultation - 1,Obstetrics / Gynecology,"obstetrics / gynecology, gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,"
Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.,"PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,  Revision rhinoplasty (CPT 30450).  Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture.  During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma.  The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect.  The patient was consented for the above-stated procedure.  The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion.  The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues.  In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear.  Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb.  Betadine was utilized for preparation.  A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane.  I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested.  These were placed aside in saline.  Hemostasis was obtained with bipolar electrocauterization.  Bovie electrocauterization was also employed as needed.  The entire length of the wound was then closed with 5-0 plain running locking suture.  The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture.  Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose.  A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision.  The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums.  Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum.  At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip.  The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect.  Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome.  These were done transmucosally after elevating the tract using a Cottle elevator.  Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms.  The patient had a series of double-dome sutures placed into the nasal tip.  Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing.  Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation.  A Gore-Tex small implant had been selected, previously incised.  This was taken to the back table and carved under sterile conditions.  The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum.  It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut.  The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage.  This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis.  The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures.  The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic.  There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum.  The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition.  He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area.  He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.",Revision Rhinoplasty.,ENT - Otolaryngology,"ent - otolaryngology, nasal deformity, rhinoplasty, conchal cartilage harvest, conchal bulb, conchal, submucoperichondrial, gull-wing incision, gore-tex, gull wing incision, lower lateral cartilages, revision rhinoplasty, nasal dorsum, cartilage harvest, conchal cartilage, cartilage, nasal, deformity, hemostasis, columella, harvest, cartilages"
The patient had undergone mitral valve repair about seven days ago.,"PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.",Mediastinal Exploration & Right Atrium Repair,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,"
"Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.  Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.","PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:,  Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:,  Zero.,SPECIMENS,1.  Inflammatory synovitis from the volar radial wrist area.,2.  Inflammatory synovitis from the dorsal wrist area.,DRAINS:,  None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff.  Routine prep and drape was employed.  Patient received 1 gm of IV Ancef preoperatively.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet.  Tourniquet inflated to 250 mmHg pressure.  Hand positioned palm up in a lead hand-holder.  A longitudinal zigzag incision over the volar radial wrist mass was made.  Skin was sharply incised.  Careful blunt dissection was used in the subcutaneous tissue.  Antebrachial fascia was bluntly dissected and incised to reveal the radial artery.  Radial artery was mobilized preserving its dorsal and palmar branches.  Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery.  Wrist mass was exposed by blunt dissection.  This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule.  This was debrided down to the wrist capsule with visualization of the joint through a small capsular window.  After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture.  Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene.  Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision.  An oblique incision overlying the radial styloid centered on the second extensor compartment was made.  Skin was sharply incised.  Blunt dissection was used in the subcutaneous tissue.  Care was taken to identify and protect the superficial radial nerve.  Blunt dissection was carried out in the extensor retinaculum.  This was incised longitudinally over the second extensor compartment.  EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury.  The interval between the ECRL and the ECRB was developed down to bone.  Dorsal capsulotomy was made and local synovitis was identified.  This was debrided and sent as second pathologic specimen.  Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis.  Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer.  Dorsally the styloidectomy was beveled smooth and contoured with a rongeur.  Final x-rays documenting the styloidectomy were obtained.  Local synovitis beneath the joint capsule was debrided.  Remnants of the scapholunate interosseous which was completely deteriorated were debrided.  The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS.  Subcutaneous tissues closed with 4-0 Vicryl.  Skin was closed with running subcuticular 4-0 Prolene.  Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia.  A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1.  Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2.  Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3.  Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.",Styloidectomy,Orthopedic,"orthopedic, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass"
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.,"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.",Barium Swallow Study & Speech Evaluation,Gastroenterology,
Upper endoscopy with removal of food impaction.,"PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.",Upper Endoscopy,Gastroenterology,"gastroenterology, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus,"
Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",Anterior Cervical Discectomy,Orthopedic,
A white female presents for exam and Pap.,"SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",Physical Exam and Pap - 2,Obstetrics / Gynecology,
The patient seeks evaluation for a second opinion concerning cataract extraction.,"SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,",Cataract - Second Opinion,Ophthalmology,"ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,"
Bilateral breast MRI with & without IV contrast.,"FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.",MRI Breast - 1,Obstetrics / Gynecology,"obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast"
The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.",CyberKnife Treatment - Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,"
Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,"ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, ""mass like"" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.",Pneumonia & COPD - Discharge Summary,Cardiovascular / Pulmonary,
"Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.","PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.",Laminectomy & Foraminotomy Revision,Neurosurgery,
Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",Falls - Discharge Summary,Neurology,
"Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.","PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",Anterior Cervical Discectomy & Decompression,Orthopedic,
"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.","REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",Colon Cancer Consult,Gastroenterology,
Diagnosis of benign rolandic epilepsy.,"City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.",Rolandic Epilepsy,Neurology,"neurology, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,"
"Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.","PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1.  Anterior cervical discectomy of C3-C4.,2.  Removal of herniated disc and osteophytes.,3.  Bilateral C4 nerve root decompression.,4.  Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5.  Grafting of fibular allograft bone for creation of arthrodesis.,6.  Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7.  Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain.  Conservative therapy has failed to improve the problem.  Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives.  He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses.  The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck.  Dissection was carried down through the platysmal musculature and the anterior spine was exposed.  The medial borders of the longus colli muscles were dissected free from their attachments to the spine.  A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space.  Castoff self-retaining pins were placed into the body of the C3 and C4.  Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed.  Quite a bit of overhanging osteophytes were identified and removed.  As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs.  A high-speed diamond bur was used to slowly drill these spurs away.  I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen.  The dura was extremely thin and I could see through it in several areas.  I removed the bony compression in the foramen and identified soft tissue and veins overlying the root.  All of these were not stripped away for fear of tearing this very tissue-paper-thin dura.  However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen.  An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration.  Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis.  As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally.  Under distraction the graft was placed and fit well.  An x-ray showed good graft placement.,Attention was turned to spinal instrumentation.  A Synthes Short Stature plate was used with four 3-mm screws.  Holes were drilled with all four screws were placed with pretty good purchase.  Next, the locking screws were then applied.  An x-ray was obtained which showed good placement of graft, plate, and screws.  The upper screws were near the upper endplate of C3.  The C3 vertebral body that remained was narrow after drilling off the spurs.  Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure.  A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied along with a rigid Philadelphia collar.  The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.",Anterior Cervical Discectomy - 1,Orthopedic,"orthopedic, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft,"
CT REPORT - Soft Tissue Neck,"FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing area with a mean attenuation coefficient of 28.1 HU, suggesting an area of central necrosis. There is the suggestion of mild peripheral rim enhancement. This large lesion within the deep lobe of the parotid gland abuts and effaces the facial nerve. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation would be necessary for definitive diagnosis. The right parotid gland is normal.,There is mild enlargement of the left jugulodigastric node, measuring 1.1cm in size, with normal morphology (image #33/68). There is mild enlargement of the right jugulodigastric node, measuring 1.2cm in size, with normal morphology (image #38/68).,There are demonstrated bilateral deep lateral cervical nodes at the midlevel, measuring 0.6cm on the right side and 0.9cm on the left side (image #29/68). There is a second midlevel deep lateral cervical node demonstrated on the left side (image #20/68), measuring 0.7cm in size. There are small bilateral low level nodes involving the deep lateral cervical nodal chain (image #15/68) measuring 0.5cm in size.,There is no demonstrated nodal enlargement of the spinal accessory or pretracheal nodal chains.,The right parotid gland is normal and there is no right parotid gland mass lesion.,Normal bilateral submandibular glands.,Normal parapharyngeal, retropharyngeal and perivertebral spaces.,Normal carotid spaces.,IMPRESSION:,Large, well demarcated mass lesion of the deep lobe of the left parotid gland, with probable involvement of the left facial nerve. See above for size, morphology and pattern enhancement. Primary consideration is of a benign mixed tumor (pleomorphic adenoma), however, other solid mass lesions cannot be excluded, for which histologic evaluation is necessary for specificity.,Multiple visualized nodes of the bilateral deep lateral cervical nodal chain, within normal size and morphology, most compatible with mild hyperplasia.",CT Neck - 2,Orthopedic,"orthopedic, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep"
"Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.","PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.",Laparoscopic Gastric Bypass,Gastroenterology,"gastroenterology, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric"
A lady was admitted to the hospital with chest pain and respiratory insufficiency.  She has chronic lung disease with bronchospastic angina.,"We discovered new T-wave abnormalities on her EKG.  There was of course a four-vessel bypass surgery in 2001.  We did a coronary angiogram.  This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d.  This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case.  She also is on an ACE inhibitor.,So her discharge meds are as follows:,1.  Coreg 6.25 mg b.i.d.,2.  Simvastatin 40 mg nightly.,3.  Lisinopril 5 mg b.i.d.,4.  Protonix 40 mg a.m.,5.  Aspirin 160 mg a day.,6.  Lasix 20 mg b.i.d.,7.  Spiriva puff daily.,8.  Albuterol p.r.n. q.i.d.,9.  Advair 500/50 puff b.i.d.,10.  Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks.  She is to follow up with Dr. X before that.",Chest Pain & Respiratory Insufficiency,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic"
Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,"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.",Tessio Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia.,"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",Neck & Lower Back Pain - Consult,Neurology,
"Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.","DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.",Delivery Note - 8,Obstetrics / Gynecology,"obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Initial evaulation - neck and back pain.,"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",Neck & Back Pain,Orthopedic,
Routine colorectal cancer screening.  He occasionally gets some loose stools.,"HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.",Colon Cancer Screening,Hematology - Oncology,"hematology - oncology, colon cancer screening, loose stools, colorectal, colonoscopy,"
"Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.","REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",Preeclampsia,Cardiovascular / Pulmonary,
"Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.","PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.",Lobectomy & Lymphadenectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest"
"MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.","CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as ""word salad"" and ""complete gibberish."" She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of ""word salad."" When asked how he was, he replied: ""abadeedleedlebadle."" Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a ""faucet dripping"" as a ""faucet drop."" He called ""red"" ""reed."" Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to ""1,200."",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.",MRI Brain - Wernicke aphasia,Neurology,"neurology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain,"
Direct-current cardioversion.  This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  Successful DC cardioversion of atrial fibrillation.,"PROCEDURE:  ,Direct-current cardioversion.,BRIEF HISTORY:  ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  He had a wide area of circumferential ablation done on November 9th for atrial fibrillation.  He did develop recurrent atrial fibrillation the day before yesterday and this is persistent.  Therefore, he came in for cardioversion today.  He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices.  After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s.  He tolerated it well.  He will be observed for couple hours and discharged home later today.  He will continue on his current medications.  He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.",Cardioversion - Direct Current - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,"
"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.","REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",Colon Cancer Consult,Hematology - Oncology,
Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.",Pituitary Adenomectomy,Neurology,
"EGD with PEG tube placement using Russell technique.  Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.","PREOPERATIVE DIAGNOSES:,1.  protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1.  Protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,3.  Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS:  ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service.  She has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  She states that her decreased p.o. intake has been progressively worsening.  She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  She was placed in the supine position.  The area was prepped and draped in the sterile fashion.  After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  The esophagus, stomach, and duodenum were visualized without difficulty.  There was no gross evidence of any malignancy.  There was some enterogastritis which was noted upon exam.  The appropriate location was noted on the anterior wall of the stomach.  This area was localized externally with 1% lidocaine.  Large gauge needle was used to enter the lumen of the stomach under visualization.  A guide wire was then passed again under visualization and the needle was subsequently removed.  A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach.  The balloon was then insufflated and the break-away sheath was then pulled away.  Proper placement of the tube was ensured through visualization with a scope.  The tube was then sutured into place using nylon suture.  Appropriate sterile dressing was applied.,DISPOSITION:  ,The patient was transferred to the recovery in a stable condition.  She was subsequently returned to her room on the General Medical Floor.  Previous orders will be resumed.  We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.",EGD & PEG Tube Placement,Gastroenterology,"gastroenterology, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis"
Arthroplasty of the right second digit.  Hammertoe deformity of the right second digit.,"PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.",Arthroplasty - Hammertoe,Orthopedic,"orthopedic, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon"
"Chest, Single view post OP for ASD (Atrial Septal Defect).","EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.",Single Frontal View of Chest,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial septal defect, central venous catheter, bilateral basilar atelectasis, single frontal view, distal tip, endotracheal tube, sternotomy wires, basilar atelectasis, atrial, venous, catheter, endotracheal, tube, sternotomy, atelectasis, chest, asd"
Foraminal disc herniation of left L3-L4.  Enlarged dorsal root ganglia of the left L3 nerve root.  Transpedicular decompression of the left L3-L4 with discectomy.,"PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1.  Foraminal disc herniation of left L3-L4.,2.  Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain.  An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root.  Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally.  There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal.  I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root.  But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient.  So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney.  Department of Anesthesia administered general anesthetic.  Endotracheal intubation followed.  The patient received the Foley catheter.  She was then placed in a prone position on a Jackson table.  Bony prominences were well padded.  Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion.  A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3.  Retractors were placed into the wound to retract the musculature.  At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified.  A marker was placed over the pedicle of L3 and confirmed radiographically.  Next, a microscope was brought onto the field.  The remainder of the procedure was noted with microscopic visualization.  A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis.  At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen.  As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI.  A discectomy was performed at this time removing only small portions of the lateral aspect of the disc.  Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance.  The medial aspect with the axilla of the nerve root appears to be enlarged.  The color of the tissue was consistent with a nerve root tissue.  There was no identifiable plane and this is a gentle enlargement of the nerve root.  There are no circumscribed lesions or masses that can easily be separated from the nerve root.  As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure.  So, at this point there is no further decompression.  A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral.  The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially.  The wound was then irrigated copiously and suctioned dry.  A concoction of Duramorph and ______ was then placed over the nerve root for pain control.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision.  The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.",Transpedicular Decompression,Orthopedic,"orthopedic, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal"
Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.,"PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",Anterior Cervical Discectomy & Interbody Fusion - 2,Orthopedic,"orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,"
Dobutamine stress test for atrial fibrillation.,"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 Dobutamine,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial"
"C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.","PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.",Anterior Cervical Discectomy - 4,Neurosurgery,"neurosurgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,"
Twin pregnancy with threatened preterm labor.,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:",Ultrasound OB - 4,Radiology,
"Left heart catheterization, coronary angiography, left ventriculography.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.","PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration.  A 6-French arterial sheath was placed in the usual fashion.  Left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  The right coronary artery was difficult to cannulate because of its high anterior takeoff.  This was nondominant.  Several catheters were used.  Ultimately, an AL1 diagnostic catheter was used.  A pigtail catheter was advanced across the aortic valve.  Left ventriculogram was then done in the RAO view using 30 mL of contrast.  Pullback gradient was obtained across the aortic valve.  Femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a Perclose device with good results.  There were no complications.  He tolerated this procedure well and returned to his room in good condition.,FINDINGS,1.  Right coronary artery:  This has an unusual high anterior takeoff.  The vessel is nondominant, has diffuse mild-to-moderate disease.,2.  Left main trunk:  A 30% to 40% distal narrowing is present.,3.  Left anterior descending:  Just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  The diagonal is a large vessel about 3 mm in size.,4.  Circumflex:  Dominant vessel, 50% narrowing at the origin of the obtuse marginal.  After this, there is 40% narrowing in the AV trunk.  The small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.,5.  Left ventriculogram:  Normal volume in diastole and systole.  Normal systolic function is present.  There is no mitral insufficiency or left ventricular outflow obstruction.,DIAGNOSES,1.  Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  Dominant circumflex system.  Severe disease of the posterior descending.  Mild left main trunk disease.,2.  Normal left ventricular systolic function.,Given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  The patient also has severe disease of the circumflex which is dominant.  This anatomy is not appropriate for percutaneous intervention.  The case will be reviewed with a cardiac surgeon.","Heart Catheterization, Ventriculography, & Angiography - 7",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,"
Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,"PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.",Cardiac Catheterization - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization,"
"Release of A1 pulley, right thumb.   Stenosing tendinosis, right thumb (trigger finger).  There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.","PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:,  Release of A1 pulley, right thumb.,ANESTHESIA:,  IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY:  ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb.  She was actually able to spontaneously trigger the thumb.  She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley.  All risks and benefits of the surgery was discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE:  ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table.  A regional anesthetic was applied by the Anesthesia Department.  Tourniquet was placed on her proximal arm.  The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The nerves were identified and retracted throughout the entire procedure.  The fibers of the A1 pulley were identified.  They were sharply dissected to release the tendon.  The tendon was then pulled up into the wound and inspected.  There was no evidence of gross tear noted.  Fibrous nodule was noted within the tendon itself.  There was no evidence of continuous locking.  Once release of the pulley had been performed, the wound was copiously irrigated.  It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures.  Sterile dressing was applied to the upper extremity.  Tourniquet was deflated.  It was noted that the thumb was warm and pink with good capillary refill.  The patient was transferred to Recovery in apparent stable and satisfactory condition.  Prognosis is fair.",Release of A1 Pulley - 1,Orthopedic,"orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley"
"Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.","PROCEDURE:,  Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed.  The patient received topical lidocaine by nebulization.  The flexible fiberoptic bronchoscope was introduced orally.  The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions.  I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe.  I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies.  Followup fluoroscopy was negative for pneumothorax.  I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions.  I performed a bronchial washing after the biopsies in the right upper lobe.  I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area.  All of these samples were sent for histology and cytology respectively.  Estimated blood loss was approximately 5 cc.  Good hemostasis was achieved.  The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well.  Her ASA score was 2.",Bronchoscopy - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Patient with history of adenomas and irregular bowel habits.,"PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas.  She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one.  There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2.  There were small internal hemorrhoids.  The remainder of the examination was normal to the cecum.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Two colon polyps, removed.,2.  Small internal hemorrhoids.,3.  Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology.  The patient was told the importance of daily fiber.",Colonoscopy - 7,Gastroenterology,"gastroenterology, colon polyps, internal hemorrhoids, rectum, irregular bowel habits, colon polyps removed, irregular bowel, bowel habits, polyps removed, bowel, habits, colonoscope, hemorrhoids, cecum, forceps, polyps, colonoscopy, adenomas,"
The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.,"GROSS DESCRIPTION:,A.  Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.  There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B.  Received fresh, labeled with patient's name, designated ""lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C.  Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung.  The lung is inflated with formalin.  There is a 12.0 cm staple line on the lateral surface, inked blue.  There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line.  The overlying pleura is puckered.,D.  Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E.  Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A.  Right upper lobe wedge lung biopsy:  Poorly differentiated non-small cell carcinoma.  Tumor Size:  0.8 cm.  Arterial (large vessel) invasion:  Not seen.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,B.  Biopsy, 10R lymph node:  Anthracotically pigmented lymphoid tissue, negative for malignancy.,C.  Right upper lobe, lung:  Moderately differentiated non-small cell carcinoma,(adenocarcinoma).  Tumor Size:  1.3 cm.  Arterial (large vessel) invasion:  Present.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,D.  Biopsy, 4R lymph nodes:  Lymphoid tissue, negative for malignancy.,E.  Biopsy, subcarinal lymph node:  Lymphoid tissue, negative for malignancy.,COMMENTS:,  Pathologic examination reveals two separate tumors in the right upper lobe.  They appear histologically distinct, suggesting they are separate primary tumors (pT1).  The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.  The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.",Lung Biopsy Pathology Report - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy"
"Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.","SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.",Nephrolithiasis - Progress Note,Nephrology,"nephrology, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications,"
Left retrosigmoid craniotomy and excision of acoustic neuroma.,"PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.",Craniotomy - Retrosigmoid,Neurosurgery,"neurosurgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor"
Scarf bunionectomy procedure of the first metatarsal of the left foot.  Hallux abductovalgus deformity with bunion of the left foot.,"PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:,  IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion.  The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes.  The patient has failed to conservative treatment and desires surgical correction at this time.  Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:,  After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously.  The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection.  Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection.  After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg.  The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot.  After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon.  Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery.  A neurovascular bundle was identified and reflected medially.  Laterally the extensor hallucis longus tendon was identified and protected with retraction as well.  Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully.  The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule.  The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree.  Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx.  Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint.  The bone cortex was noted to be intact and in good condition.  Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head.  In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected.  Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well.  Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head.  Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal.  A second 0.45 K-wire was inserted proximally as well.  Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral.  After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made.  This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal.  Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone.  Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially.  The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone.  Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction.  Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit.  The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex.  Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved.  Intramedullary sludge was noted to exit from the osteotomy cut.  Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked.  Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap.  Following this, a 20 mm full threaded screw was inserted and tightened.  Good intramedullary sludge was noted and compression was achieved.  Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite.  Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted.  Based on this, a lateral release was performed.  The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace.  The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected.  Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament.  Upon completion of this, the hallux was noted to be in a rectus position with good alignment.  The area was then flushed and irrigated with copious amounts of sterile saline.  After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture.  Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers.  The skin was then reapproximated and closed using #5-0 Monocryl suture.  Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing.  The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg.  The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot.  The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit.  Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain.  The patient was also given prescription for clindamycin to be taken 300 mg four times a day.  The patient was given surgical shoe and was placed in a posterior sling.  The patient was given crutches and instructed to use them for ambulation.  The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend.  The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office.  The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that.  The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise.  X-rays were taken and the patient was discharged home upon completion of this.",Scarf Bunionectomy,Orthopedic,"orthopedic, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus"
Pulmonary Function Test in a patient with smoking history.,"HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%.  FEV1 was 45%.  FEV1/FVC ratio was 52%. The predicted was 67%.  FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  SVC was 91%. Inspiratory capacity was 70%.  Residual volume was 225% of its predicted.  Total lung capacity was 128%.  ,IMPRESSION:,1.  Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  Probably there is some restrictive element because of fibrosis.  The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  Diffusion capacity was not measured.  The flow volume loop was consistent with the above.,",Pulmonary Function Test - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function,"
"VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.","PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.",Lobectomy - VATS,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,"
"Marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  she had a mammogram and ultrasound, which confirmed the right breast mass.","CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:",Marginal Zone Lymphoma,Hematology - Oncology,
Pain and swelling in the right foot.,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",MRI Foot - 3,Radiology,
Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery,"HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.",Preop Cardiac Consult,Cardiovascular / Pulmonary,
MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.",MRI Brain & Cerebral Angiogram,Neurology,
Esophagogastroduodenoscopy with bile aspirate.  Recurrent right upper quadrant pain with failure of antacid medical therapy.  Normal esophageal gastroduodenoscopy.,"PREOPERATIVE DIAGNOSIS:,  Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain.  Despite antacid therapy, the patient's pain has continued.  Additional findings were concerning with possibility of a biliary etiology.  The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed.  The patient agreed to the procedure and informed consent was obtained.,GROSS FINDINGS: , No evidence of neoplasia, mucosal change, or ulcer on examination.  Aspiration of the bile was done after the administration of 3 mcg of Kinevac.,PROCEDURE DETAILS: , The patient was placed in the supine position.  After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum.  Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile.  At this time, the patient as well complained of epigastric discomfort and nausea.  This pain was similar to her previous pain.,Bile was aspirated with a trap to enable the collection of the fluid.  This fluid was then sent to lab for evaluation for crystals.  Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted.  The gastroesophageal junction was noted at 20 cm.  No other evidence of disease was appreciated here.  Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient.  The patient tolerated the procedure well.  We will await evaluation of bile aspirate.",Esophagogastroduodenoscopy - 11,Gastroenterology,"gastroenterology, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope"
"Bronchoscopy brushings, washings and biopsies.  Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.","OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.",Bronchoscopy Brushings,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised"
"Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.","DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.",Induction of Vaginal Delivery,Obstetrics / Gynecology,"obstetrics / gynecology, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars"
Patient with right ankle pain.,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",MRI Ankle - 1,Orthopedic,
MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",MRI Brain - Toxoplasmosis,Radiology,
Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to 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",Acute Inferior Myocardial Infarction,Cardiovascular / Pulmonary,
Patient referred for evaluation of her left temporal lobe epilepsy.,"REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,",Consult - Seizures,Neurology,
Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound.,"PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,",Chest Tube Removal,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest"
The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.,"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.",Abdominal Pain - Consult,Gastroenterology,
MRI left knee without contrast.,"EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.",MRI Knee - 1,Orthopedic,"orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament,"
MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,"CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.",Acute Intracerebral Hemorrhage,Neurology,
Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.,"PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.",ORIF - 1,Orthopedic,"orthopedic, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar"
"Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.","PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.",BCCa Excision - Lower Lid,Ophthalmology,"ophthalmology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival,"
"Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.","PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",Anterior Cervical Discectomy & Decompression,Neurosurgery,
"Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.","PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.",Dual Chamber ICD Implantation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,"
"Organic brain syndrome in the setting of multiple myeloma.  The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.","REASON FOR CONSULT:,  Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY:  ,The patient himself is not able to give a good history.  History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.  Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room.  Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma.  The patient since the morning has improved, but still not completely back to the baseline.  Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:,  History of IgG subtype multiple myeloma.,SURGICAL HISTORY:,  Nothing significant.,PSYCHIATRIC HISTORY:  ,Nothing significant.,SOCIAL HISTORY:  ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS:  ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness.  The patient himself is not able to give any history only source is the chart.  For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5.  The patient on supplemental oxygen was FiO2 on 2 L 96%.  Limited physical examination.,HEENT:  Head, normocephalic and atraumatic.  Throat clear.  No discharge from the ear and the nose.  No discoloration of conjunctivae and the sclerae.,NECK:  Supple.  No signs of any meningismus.  Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion.  No bruit auscultated over the neck and the orbits.,LUNGS:  Clear to auscultation.,HEART:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.  No rash.  No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC:  Examination is limited.  Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented.  Cranial nerve examination limited, but apparently nonfocal.  Motor examination is very limited except for the grips, which were strong enough.  I was not able to obtain much.  Deep tendon reflexes were not reliable.  Toes equivocal and downgoing.  Sensory examination is not reliable, though intact for painful stimuli with limited examination.  Coordination could not be tested.  Gait could not be tested.,IMPRESSION:,  History of multiple myeloma and altered mental status in multiple myeloma setting.  Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management.  I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection.  No other intervention at this time.  The patient may be started on aspirin, if it is okay with Dr. X.",Organic Brain Syndrome,Neurology,
Repair of bilateral cleft of the palate with vomer flaps.,"PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:,  Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE:  ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  The patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  We will proceed with surgery.,DETAILS OF THE PROCEDURE:,  The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  A prophylactic dose of antibiotics was given.  The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery.  After he was done with his procedure, the head of the bed was turned 90 degrees.  The patient was positioned with a shoulder roll and doughnut.  A Dingman retractor was placed.  The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping.  The patient was prepped and draped.  I proceeded to do the palate repair.  The nature of the palate repair was done in the same way on the both sides.  I will describe one side.  The other side was done exactly in the same manner.  The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  This triangle of nasal mucosa was removed and excised.  This was done on both uvulas.  Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  Hemostasis was achieved with help of electrocautery and Surgicel.  The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  At this point, the decision was made to proceed with vomer flaps.  The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  The incision was done with a 15C blade.  The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches.  The throat pack was removed.  The palate was cleaned.  The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm.  The patient tolerated the procedure without complications.  BSS is applied to the eye after removing the Tegaderm.  I was present and participated in all aspects of the procedure.  The sponge, needle, and instrument count were completed at the end of the procedure.  The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.",Cleft Repair,ENT - Otolaryngology,"ent - otolaryngology, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,"
"Bilateral Mammogram, (abnormal) additional views requested","EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.",Bilateral Mammogram,Obstetrics / Gynecology,"obstetrics / gynecology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,"
Bronchoscopy for persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,"INDICATIONS FOR PROCEDURE:,  Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1.  Demerol 50 mg.,2.  Phenergan 25 mg.,3.  Atropine 0.6 mg IM.,4.  Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:,  With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords.  The cords move normally with phonation and ventilation.  Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed.  Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus.  Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted.  Upper lobe and lingula were unremarkable.  There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem.  This had been a change from the prior bronchoscopy of unclear significance.  Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection.  The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic.  The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable.  The scope was withdrawn.  The patient's saturation remained 93%-95% throughout the procedure.  Blood pressure was 103/62.  Heart rate at the end of the procedure was about 100.  The patient tolerated the procedure well.  Samples were sent as follows.  Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture.  Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.",Bronchoscopy - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical,"
Repeat low transverse cervical cesarean section with delivery of a viable female neonate.  Bilateral tubal ligation and partial salpingectomy.  Lysis of adhesions.,"PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.",BTL & Salpingectomy,Obstetrics / Gynecology,
"Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.  Soft tissue mass and osteophyte lateral femoral condyle, right knee.","PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Soft tissue mass, right knee.,2.  Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:,  This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee.  On aspiration, it was originally attempted to no avail.  There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present.  During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred.  The patient continued to complain of pain and dysfunction to his calf.  This was discussed with him at length.  He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy.  With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee.  It was noted to be tender.  It was marked preoperatively prior to an anesthetic.  Upon dissection, the patient was noted to have significant thickening of the posterior capsule.  The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle.  There was also noted to be prominence of the lateral femoral condyle ridge.  The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table.  After receiving IV sedation, he was placed prone.  Thigh tourniquet was placed.  He was prepped and draped in the usual sterile manner.  A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized.  The nerve was identified and carefully retracted throughout the case.  Both nerves were identified and carefully retracted throughout the case.  There was noted to be no neuroma present.  This was taken down until the gastroc was split.  There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised.  The lateral femoral condyle was then osteophied.  We then smoothed off with a rongeur.  After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve.  Tourniquet was deflated.  It was checked again.  There was no excessive swelling.  Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were warm _______ pulses distally at the end of the case.  The tourniquet as stated has been deflated prior to closure and hemostasis was controlled.  Expected surgical prognosis on this patient is guarded.",Arthrotomy & Ostectomy & Capsular Mass Excision,Orthopedic,"orthopedic, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,"
"Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.","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.",Breast Calcifications - Preop Consult,Obstetrics / Gynecology,
Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She was admitted here and labor was confirmed with rupture of membranes.,"DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,",Delivery Note - 6,Obstetrics / Gynecology,"obstetrics / gynecology, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Colonoscopy with terminal ileum examination.   Iron deficiency anemia.  Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.,"INDICATION: , Iron deficiency anemia.,PROCEDURE:  ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:,  Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL:  ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  The ileocecal valve looked normal.  Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  The terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.  ,RECOMMENDATIONS:,  Follow up with primary care physician.",Colonoscopy - 19,Gastroenterology,"gastroenterology, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum"
GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.,"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",GI Bleed - Discharge Summary,Gastroenterology,
"A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.","PREOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal fusion.,5.  Two previous C-sections.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal effusion.,5.  Two previous C-section.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  Adhesions of bladder.,7.  Poor fascia quality.,8.  Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1.  A repeat low transverse cervical cesarean section.,2.  Lysis of adhesions.,3.  Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:,  600 cc.,HISTORY AND INDICATIONS:  ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  The uterus appeared to be intact.  This patient is a 26-year-old Caucasian female.  The patient is well known to the OB/GYN clinic.  The patient had two previous C-sections.  She appears to be in probably early labor.  She had an amniocentesis early today.  She is contracting regularly about every three minutes.  The contractions are painful and getting much more so since the amniocentesis.  The patient had fetal lung maturity noted.  The patient also has probable IUGR as none of her babies have been over 4 lb.  The patient's baby appears to be somewhat small.  The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound.  The patient has had a spinal fusion, however, family planning is definitely complete per the patient.  The patient refuses trial labor.  The patient and I discussed the consent.  She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  Her questions were answered.  The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  The patient understands this and would like to try our best.,PROCEDURE:  ,The patient was taken back to the operative suite.  She was given general anesthetic by Department of Anesthesiology.  Once again, in layman's terms, the patient understands the risks.  The patient had the informed consent reviewed and understood.  The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  The patient had the first knife went through this incision.  The second knife was used to go to the level of fascia.  The fascia was very thin, ruddy in appearance, and with abundant scar tissue.  The fascia was incised.  Following this, we were able to see the peritoneum.  There was really no obvious rectus abdominal muscles noted.  They were very weak, atrophic, and thin.  The patient has the peritoneum tented up.  We entered the abdominal cavity.  The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  The bladder flap was then entered into the uterus as well.  There are some bladder adhesions.  We removed these adhesions and we removed the bladder of the fascia.  We dissected the bladder of the lower segment.  We made a small nick on the lower segment.  We were able to utilize the blunt end of the knife to enter into the uterine cavity.  The baby was in occiput transverse position with the ear being cocked at such a position as well.  The patient's baby was delivered without difficulty.  It was a 4 lb and 10 oz baby girl who vigorously cried well.  There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  The patient's placenta was delivered.  There was no retained placenta.  The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first.  The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  Then we ligated this as there was bleeding and oozing.  The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc.  The 400 cc was instilled.  The bladder appears to be intact.  The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  There was some oozing around the area of the bladder.  We placed an Avitene there.  The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  The patient has two clips on each side.  There was excellent tubal occlusion and placement.  The uterus was placed back into the abdominal cavity.  We rechecked again.  The tubal placement was excellent.  It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  The patient then underwent further examination.  Hemostasis appeared to be good.  The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia.  We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  The Scarpa's fascia was reapproximated with #0 gut.  The skin was reapproximated then as well via subcutaneous closure.  The patient's sponge and needle counts found to be correct.  Uterus appeared to be normal prior to closure.  Bladder appeared to be normal.  The patient's blood loss is 600 cc.",Low-Transverse C-Section - 10,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal,"
Patient with a long history of depression and attention deficits.,"IDENTIFYING DATA:,  The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:,  The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:,  The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D.  Historically, he has found it very easy to be distracted in the ""cubicle"" office setting where he sometimes works.  He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder.  Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful.  In the past, probably in high school, the patient recalled being more figidity than now.  He tensed to feel anxious.  Sleep has been highly variable.  He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month.  Appetite has been good.  He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall.  He tends to feel depressed.  His energy level is ""better now,"" but this was very problematic in the past.  He has problems with motivation.  In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:,  The patient has never been hospitalized for psychiatric purposes.  His only treatment has been at this facility.  He tried Adderall for a time, and it helped, but he became hypertensive.  Lunesta is effective for his insomnia issues.  Effexor has helped to some degree.  He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success.  He sometimes takes the other half of the tablet in the afternoon.",Psychiatric Evaluation - 1,Psychiatry / Psychology,
"Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.","CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed ""fidgety movements"" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.",Huntington's Disease,Neurology,
"Bilateral degenerative arthritis of the knees.  Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.","PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.",Knee Arthroplasty,Orthopedic,"orthopedic, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia,"
"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.","IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , ""I'm here because I'm different."" The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.",Psych Consult - Bipolar Affective Disorder,Psychiatry / Psychology,
"Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.","ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.",Prematurity - Discharge Summary,Pediatrics - Neonatal,
"Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.","PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.",Anterior Cervical Discectomy & Arthrodesis - 2,Orthopedic,"orthopedic, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,"
"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.","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",Thoracotomy & Esophageal Exploration,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,"
MRI Brain: Thrombus in torcula of venous sinuses.,"CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of ""startle response (myoclonic movement of the shoulders)"" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.",MRI Brain - Thrombus,Neurology,"neurology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula"
Repair of ruptured globe with repositing of uveal tissue - Sample/Template.,"PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.",Ruptured Globe Repair - Sclera and Limbus,Ophthalmology,"ophthalmology, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,"
Esophagogastroduodenoscopy with biopsy.,"PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.",Esophagogastroduodenoscopy - 2,Gastroenterology,"gastroenterology, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy"
"Chronic cholecystitis.   Laparoscopic cholecystectomy.  Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.","PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis.,PROCEDURE PERFORMED:  ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION:  ,To recovery room and to home.,FLUIDS:  ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis.  Final pathology is pending.,INDICATIONS FOR THE PROCEDURE:  ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL:  ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities.  The anterior abdomen was then prepared and draped in a sterile fashion.  Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade.  The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg.  The epigastric and right subcostal trocars were placed under direct vision.  The right upper quadrant was well visualized.  The gallbladder was noted to be significantly distended with surrounding dense adhesions.  The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector.  Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  The cystic duct was clipped x3 and then divided.  The cystic artery was dissected out in like fashion, clipped x3, and then divided.  The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis.  Prior to removal of the gallbladder, all irrigation fluid was clear.  No active bleeding or oozing was seen.  All clips were noted to be secured and intact and in place.  The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology.  The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  The insufflation was allowed to escape.  The umbilical fascia was closed using interrupted #1 Vicryl sutures.  Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl.  Sterile dressings were applied.  The patient tolerated the procedure well.,",Laparoscopic Cholecystectomy - 8,Gastroenterology,"gastroenterology, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder,"
Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.,"REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.",Glioblastoma Multiforme - Consult,Hematology - Oncology,
"Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.","SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",Sports Physical - 3,Pediatrics - Neonatal,
"Pelvic tumor, cystocele, rectocele, and uterine fibroid.  Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.","1.  Pelvic tumor.,2.  Cystocele.,3.  Rectocele.,POSTOPERATIVE DIAGNOSES:,1.  Degenerated joint.,2.  Uterine fibroid.,3.  Cystocele.,4.  Rectocele.,PROCEDURE PERFORMED:  ,1.  Total abdominal hysterectomy.,2.  Bilateral salpingooophorectomy.,3.  Repair of bladder laceration.,4.  Appendectomy.,5.  Marshall-Marchetti-Krantz cystourethropexy.,6.  Posterior colpoperineoplasty.,GROSS FINDINGS:  The patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  She had a recent D&C and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  Curettings were negative for malignancy.  The patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,Upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  The ovaries appeared to be within normal limits.  There was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  No other pathology noted from the abdominal cavity or adhesions.  The upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  The appendix is in its normal anatomic position.  The ileum was within normal limits with no Meckel's diverticulum seen and no other gross pathology evident.  There was no evidence of metastasis or tumors in the left lobe of the liver.,Upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,OPERATIVE PROCEDURE:  The patient was taken to the Operating Room, prepped and draped in the low lithotomy position under general anesthesia.  A midline incision was made around the umbilicus down to the lower abdomen.  With a #10 Bard Parker blade knife, the incision was carried down through the fascia.  The fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 Bard Parker blade after incision was made with Mayo scissors.  A Balfour retractor was placed into the wound.  This giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  The infundibular ligament on the right side was isolated and ligated with #0 Vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 Vicryl suture.  The right round ligament was ligated with #0 Vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  The infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  An attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  After this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  The bladder was then repaired with a running locking stitch #0 Vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 Vicryl suture.  After removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  Progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight Ochsner forceps and divided from the uterus with Mayo scissors, and the straight Ochsner was placed by #0 Vicryl suture thus controlling the uterine blood supply.  The cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved Ochsner forceps, divided from the uterus with #10 Bard Parker blade knife and a curved Ochsner was placed by #0 Vicryl suture.  The cervix was again grasped with a Lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 Bard Parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  A single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  The vaginal cuff was then closed using a running #0 Vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  The round ligaments were approximated to the vaginal cuff with #0 Vicryl suture and the bladder flap approximated to the round ligaments with #000 Vicryl suture.  The ______ was re-peritonealized with #000 Vicryl suture and then the cecum brought into the incision.  The pelvis was irrigated with approximately 500 cc of water.  The appendix was grasped with Babcock forceps.  The mesoappendix was doubly clamped with curved hemostats and divided with Metzenbaum scissors.  The curved hemostats were placed with #00 Vicryl suture.  The base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 Bard Parker blade knife, and the base inverted with a pursestring suture with #00 Vicryl.  No bleeding was noted.  Sponge, instrument, and needle counts were found to be correct.  All packs and retractors were removed.  The peritoneum muscle fascia was closed in single-layer closure using running looped #1 PDS, but prior to closure, a Marshall-Marchetti-Krantz cystourethropexy was carried out by dissecting the space of Retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 Vicryl suture.  Following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  Attention was then turned to the vagina, where the introitus of the vagina was grasped with an Allis forceps at the level of the Bartholin glands.  An incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with Metzenbaum scissors.  The flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  In this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 Vicryl suture.  Excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 Vicryl suture.  The bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 Vicryl suture.  The skin was closed with a running #000 plain gut subcuticular stitch.  The vaginal vault was packed with a Betadine-soaked Kling gauze sponge.  Sterile dressing was applied.  The patient was sent to recovery room in stable condition.","Hysterectomy, BSO, & Appendectomy.",Obstetrics / Gynecology,"obstetrics / gynecology, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine, mucosa, scissors, ligament, bladder"
Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",Anterior Cervical Discectomy & Fusion - 4,Orthopedic,
MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",MRI T-L Spine - Schistosomiasis,Neurology,
Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study.,"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",Pulmonary Consultation - 1,Cardiovascular / Pulmonary,
"Hematemesis in a patient with longstanding diabetes.   Submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.  Mallory-Weiss tear, successful BICAP cautery.","PREOPERATIVE DIAGNOSIS: ,  Hematemesis in a patient with longstanding diabetes. ,POSTOPERATIVE DIAGNOSIS:  ,Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,PROCEDURE:  , The procedure, indications explained and he understood and agreed.  He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx.  A bite block was placed.  The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  Esophagus revealed distal ulcerations.  Additionally, the patient had a Mallory-Weiss tear.  This was subjected to bicap cautery with good ablation.  The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  There were no ulcerations or erosions in the stomach.  The duodenum was entered, which was unremarkable.  The instrument was then removed.  The patient tolerated the procedure well with no complications.,IMPRESSION: , Mallory-Weiss tear, successful BICAP cautery. ,We will keep the patient on proton pump inhibitors.  The patient will remain on antiemetics and be started on a clear liquid diet.",BICAP Cautery,Gastroenterology,"gastroenterology, mallory-weiss tear, submucosal hemorrhage, esophagitis, vomiting, bicap cautery, mallory weiss, diabetes, esophagus, submucosal, hemorrhage, trauma, hematemesis,"
"Presents to the ER with hematuria that began while sleeping last night.   He denies any pain, nausea, vomiting or diarrhea.","HISTORY OF PRESENT ILLNESS:,  The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A.  He is known to us from his last admission.  At that time, he was admitted with a difficulty voiding and constipation.  His urine cultures ended up being negative.  He was seen by Dr. B and discharged home on Levaquin for five days.,He presents to the ER today with hematuria that began while he was sleeping last night.  He denies any pain, nausea, vomiting or diarrhea.  In the ER, a Foley catheter was placed and was irrigated with saline.  White count was 7.6, H and H are 10.8 and 38.7, and BUN and creatinine are of 27 and 1.9.  Urine culture is pending.  Chest x-ray is pending.  His UA did show lots of red cells.  The patient currently is comfortable.  CBI is running.  His urine is clear.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  High cholesterol.,3.  Bladder cancer.,4.  Bilateral total knee replacements.,5.  Cataracts.,6.  Enlarged prostate.,ALLERGIES:,  SULFA.,MEDICATIONS AT HOME:,1.  Atenolol.,2.  Cardura.,3.  Zegerid.,4.  Flomax.,5.  Levaquin.,6.  Proscar.,7.  Vicodin.,8.  Morphine.,9.  Phenergan.,10.  Ativan.,11.  Zocor.,12.  Prinivil.,13.  Hydrochlorothiazide.,14.  Folic acid.,15.  Digoxin.,16.  Vitamin B12.,17.  Multivitamin.,SOCIAL HISTORY: , The patient lives at home with his daughter.  He does not smoke, occasionally drinks alcohol.  He is independent with his activities of daily living.,REVIEW OF SYSTEMS:,  Not additionally rewarding.,PHYSICAL EXAMINATION:,GENERAL:  An awake and alert 85-year-old gentleman who is afebrile.,VITAL SIGNS:  BP of 162/60 and pulse oximetry of 98% on room air.,HEENT:  Pink conjunctivae.  Anicteric sclerae.  Oral mucosa is moist.,NECK:  Supple.,CHEST:  Clear to auscultation.,HEART:  Regular S1 and S2.,ABDOMEN:  Soft and nontender to palpation.,EXTREMITIES:  Without edema.,He has a Foley catheter in place.  His urine is clear.,LABORATORY DATA:,  Reviewed.,IMPRESSION:,1.  Hematuria.",Hematuria - ER Visit,Nephrology,
"The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.","HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much ""it hurts."",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.",Left Lower Quadrant Pain - ER Visit,Obstetrics / Gynecology,
A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.,"REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general ""OK,"" but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.",Dilated Cardiomyopathy - Consult,Cardiovascular / Pulmonary,
Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.,"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.",Stress Test Adenosine Myoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan"
Appendicitis.  Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion.  Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.  The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed.  No leakage of enteral contents was noted.  All trocars were removed under direct visualization.  The umbilical fascia was closed with interrupted 0 Vicryl sutures.  The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's.  The patient was extubated and taken to the recovery area in stable condition.  The patient tolerated the procedure well.",Laparoscopic Appendectomy - 2,Gastroenterology,"gastroenterology, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical"
"Repeat low-transverse cesarean section via Pfannenstiel incision.  Intrauterine pregnancy at 39 and 1/7th weeks.  Previous cesarean section, refuses trial of labor.  Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:,  Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  1200 cc.,FLUIDS:,  2700 cc.,URINE:,  400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS:  ,Placenta, cord gases and cord blood.,INDICATIONS:  ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions.  She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm.  A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally.  There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained.  The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery.  She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this.  After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered.  She was then prepped and draped in the normal sterile fashion.  Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered.  Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife.  The fascia was incised in the midline with a second knife.  This incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps.  It was then dissected in the midline with Mayo scissors.  The inferior aspect of this incision was then addressed in a similar manner.  The rectus muscles were then separated in the midline with a hemostat.  The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly.  Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors.  This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly.  Next, the bladder blade was placed.  The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors.  This incision was extended laterally in both directions and a bladder flap was created digitally.  The bladder blade was then reinserted.  Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife.  Next, the uterine incision was extended laterally in both directions with the banded scissors.  Next, the infant's head and body were delivered without difficulty.  There was multiple section on the abdomen.  The cord was clamped and cut.  Section of cord was collected for gases and the cord blood was collected.  Next, the placenta was manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The edges of the uterine incision were then identified with Allis _______ clamps.  The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis.  One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid.  After several minutes of observation, the hematoma was seem to be non-expanding.  The uterus was replaced in the abdomen.  The uterine incision was reexamined and seem to be continuing to be hemostatic.  The pelvic gutters were then cleared of all clots and debris.  The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion.  The peritoneum was then closed with #0 Vicryl in a running fashion.  The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch.  The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x3.  The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.",Low-Transverse C-Section - 7,Obstetrics / Gynecology,
"Ultrasound abdomen, complete","EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi.",Ultrasound - Abdomen,Gastroenterology,"gastroenterology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound"
Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy.,"CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",Non-Hodgkin lymphoma Followup,Hematology - Oncology,
Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation,"PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.",Anterior Cervical Discectomy & Osteophytectomy,Orthopedic,
"Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.","CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,",Lung Biopsy Pathology Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node"
"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.","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.",Atrial Fibrillation Management,Cardiovascular / Pulmonary,
Right upper lung lobectomy.  Mediastinal lymph node dissection,"OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.",Lobectomy & Lymph Node Dissection,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches"
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.,"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 - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic"
"New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.","REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.",Non-Small Cell Lung Cancer - Consult,Hematology - Oncology,
GI Consultation for Chrohn's disease.,"PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.",GI Consultation - 3,Gastroenterology,
The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.,"HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.",Supraventricular Tachycardia - Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,"
The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.,"REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.",Consult - Normal Pressure Hydrocephalus,Neurology,
"Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.","PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.",Microlaryngoscopy,ENT - Otolaryngology,"ent - otolaryngology, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,"
CCTA with Cardiac Function/Calcium Scoring,"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.",Coronary CT Angiography (CCTA) - 0,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,"
Psychiatric evaluation for major depression without psychotic features.,"IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:,  Depression.,HISTORY OF PRESENT ILLNESS:,  The patient's depression began in her teenage years.  Sleep has been poor, for multiple reasons.  She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  The patient tends to feel irritable, and has crying spells.  She sometimes has problems with motivation.  She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change.  Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine.  She does not have suicidal thoughts.  ,The patient also has what she describes as going into a ""panic mode.""  During these times, she feels as if her whole body is going to explode.  She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  These spells may last a couple of hours, but once lasted for about two day.  She does not get chest pain.  These attacks tend to be precipitated by bills that cannot be paid, or being on a ""time crunch."" ,PSYCHIATRIC HISTORY:,  The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking.  Although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times.  At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  She has never been hospitalized for psychiatric purposes.  She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine:  The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco:  She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day.  She is still committed to quitting.,Alcohol: Denied.,Illicit drugs:  Denied.  In her earlier years, someone once put some unknown drug in her milk, and she ""came to"" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional:  See History of Present Illness. No recent fever or sweats.",Psychiatric Evaluation - 2,Psychiatry / Psychology,
"The patient with recurrent nongranulomatous anterior iritis and most recently, pain in  left eye associated with headache and photophobia.","PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:,  Positive for only for left knee arthritis.  She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers.  She has no skin rashes.  She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left.  There is an afferent pupillary defect on the right.  On examination, there is a right hypertropia.  There is dense anterior chamber inflammation on the right eye with a stagnant aqueous.  There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern.  This seems to be complete iris synechia to the anterior lens capsule.  There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface.  The anterior chamber appears narrow.  On the left, there is also dense inflammation at 4+ cell.  There is 1+ nuclear sclerosis.  Dilated fundus examination cannot be performed on the right secondary to intense inflammation.  On the left, there is no evidence of active posterior uveitis.  There is some inferior vitreous debris.,ASSESSMENT/PLAN:,  Chronic bilateral recurrent nongranulomatous diffuse uveitis.  Currently, there is very severe right eye inflammation and severe left eye.  I discussed at length with the patient that this will likely take an oral steroid to quite her down.  Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible.  She has been on oral steroids in the past.  We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left.  I anticipate we will likely start methotrexate in the near future.  In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate.  We will watch her closely in clinic.  I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past.  At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR.  Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.",Uveitis,Ophthalmology,"ophthalmology, iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation,"
The patient was running and twisted her right ankle - right ankle sprain.,"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.",Ankle Pain - Consult,Orthopedic,
"Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.",Low-Transverse C-Section - 3,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,"
"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.","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.",C. Diff Colitis Consult,Gastroenterology,
"Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.","PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.",Anterior Cervical Discectomy & Fusion - 1,Orthopedic,"orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion"
"A 49-year-old female with ankle pain times one month, without a specific injury.","EXAM:,MRI LEFT FOOT,CLINICAL:, A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,FINDINGS:,Received for second opinion interpretations is an MRI examination performed on 05/27/2005.,There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.,There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,Normal peroneal tendons.,There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.,Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.,Normal distal tibiofibular syndesmotic ligamentous complex.,Normal lateral, subtalar and deltoid ligamentous complexes.,There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,Normal plantar fascia. There is no plantar calcaneal spur.,There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,IMPRESSION:,Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,Normal plantar fascia and no plantar fasciitis.,Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.",MRI Foot - 3,Orthopedic,"orthopedic, lateral plantar cutaneous, plantar cutaneous nerves, posterior tibialis tendon, medial and lateral, subcutis adipose, adipose space, achilles tendon, tendon thickening, hallucis longus, lateral plantar, plantar cutaneous, cutaneous nerves, medial malleolus, posterior tibialis, tibialis tendon, plantar, tendon, posterior, flexor, tibialis, medial,"
"Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.","PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.",Heart Catheterization - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms"
Left and right coronary system cineangiography.  Left ventriculogram.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,"REASON FOR CATHETERIZATION:,  ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Left ventriculogram.,4.  PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,PROCEDURE: , After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac cath suite.  Right groin was prepped in usual sterile fashion.  Right common femoral artery was cannulated with the modified Seldinger technique.  A 6-French sheath was introduced.  Next, Judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views.  Next, an EBU 3.5 guide was used to engage the left coronary system.  Cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis.  Angiomax bolus and drip were started after checking an ACT, which was 180, and an Universal wire was advanced through the left circumflex beyond the lesion.  Next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion.  Next a 3.5 x 12 mm Vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres.  There was noted to be a plaque shift proximally at the edge of the stent.  Therefore, a 3.5 x 8 mm Vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres.  Next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds.  Final images showed excellent results with initial 99% stenosis reduced to 0%.  The patient continues to have residual stenosis in the mid to distal in the OM branch.  At this point, wire was removed.  Final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressure was measured.  LV gram was done in both the LAO and RAO projections and a pullback gradient across the aortic valve was done and recorded.  Finally, all guides were removed.  Right femoral artery access site was imaged and Angio-Seal deployed to attain excellent hemostasis.  The patient tolerated the procedure very well without complications.,DIAGNOSTIC FINDINGS,1.  Left main:  Left main is a large-caliber vessel bifurcating in LAD and left circumflex with no significant disease.,2.  The LAD:  LAD is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3.  Left circumflex:  Left circumflex is a large-caliber vessel, gives off a large distal PDA branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the OM, which is a distal branch.,4.  Right coronary artery:  Right coronary artery is a moderate-caliber vessel, dominant, bifurcates into PDA and PLV branches, has only mild disease.  Otherwise, no significant stenosis noted.,5.  LV:  The LVEF 50%.  Inferolateral wall hypokinesis.  No significant mitral regurgitation.  No gradient across the aortic valve on pullback.,ASSESSMENT AND PLAN: , ST-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm Vision bare-metal stent and a 3.5 x 8 mm Vision bare-metal stent.  Excellent results, 0% residual stenosis.  The patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels.  Therefore, we will aggressively treat this patient medically with close followup as an outpatient.",Cineangiography - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventriculogram, circumflex, bare-metal stents, myocardial infarction, st-elevation, coronary system cineangiography, infarction, stents, cineangiography, stenosis,"
Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia,"PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.",Esophagogastroduodenoscopy,Gastroenterology,"gastroenterology, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,"
The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  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:",Neuro Consult - Leg Weakness,Neurology,
"GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.","PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.",GI Consultation - 0,Gastroenterology,
Flexible bronchoscopy  to evaluate the airway (chronic wheezing).,"PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.",Flexible Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,"
"True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.","PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.",True Cut Needle Biopsy - Breast,Hematology - Oncology,"hematology - oncology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast,"
"Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.","PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.",Carotid Endarterectomy & Angioplasty.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy"
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.,"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.",Ventricular Ectopy - Consult,Cardiovascular / Pulmonary,
"Diagnostic bronchoscopy and limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.  Bilateral bronchopneumonia and empyema of the chest, left.","PREOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,POSTOPERATIVE DIAGNOSES,1.  Bilateral bronchopneumonia.,2.  Empyema of the chest, left.,PROCEDURES,1.  Diagnostic bronchoscopy.,2.  Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed.  Initially, the patient was intubated with a #6 French tube because of the presence of previous laryngectomy.  Because of this, I proceeded to use a pediatric bronchoscope, which provided limited visualization, but I was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated.,Then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope.  Therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems.  Some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast.,Then, the patient was turned with left side up and prepped for a left thoracotomy.  He was properly draped.  I had recently re-inspected the CT of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space.  Immediately, it was evident that there was a large amount of pus in the left chest.  We proceeded to insert the suction catheters and we rapidly obtained about 1400 mL of frank pus.  Then, we proceeded to open the intercostal space a bit more with a Richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung.  We spent several minutes trying to clean up this area.  Initially, I had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure.  On the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations.  We followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex.,The limited thoracotomy was closed with heavy intercostal sutures of Vicryl, then interrupted sutures of #0 Vicryl to the muscle layers, and I loosely approximately the skin with a few sutures of nylon because I am suspicious that the incision may become infected because he has been exposed to intrapleural pus.,The chest tubes were secured with sutures and then connected to Pleur-evac.  Then, the patient was transported.,Estimated blood loss was minimal and the patient tolerated the procedure well.  He was extubated in the operating room and he was transferred to the ICU to be admitted.  A chest x-ray was ordered stat.",Bronchoscopy & Thoracotomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest tubes, insertion, partial pulmonary decortication, thoracotomy, bronchoscopy, empyema, bronchopneumonia, diagnostic bronchoscopy, pulmonary decortication, bilateral bronchopneumonia, decortication, intercostal, pulmonary, tubes,"
"Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine.  Nondiagnostic dobutamine stress test.   Normal nuclear myocardial perfusion scan.","EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT.",Dobutamine Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress,"
Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.,"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.",Tracheostomy Tube Consult,Cardiovascular / Pulmonary,
"The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.","HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.",Consult - Migraine,Neurology,
Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,"PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury.  See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1.  Normal electrophysiologic studies.,2.  No inducible arrhythmia.,3.  Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1.  Comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies.  She received small amounts of intravenous fentanyl and Versed for conscious sedation.  Then 1% lidocaine local anesthesia was used.  Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle.  Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:,  Conduction intervals in sinus rhythm were normal.  Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms.  Sinus node recovery times were also normal at 1114 ms.  Corrected sinus node recovery time was normal at 330 ms.  One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms.  AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  RA-ERP was 250 ms.  With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  There was no inducible VT.  Longest run was 5 beats of polymorphic VT, which is a nonspecific finding.  From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes.  There were no ST segment changes.  HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies.  No evidence for sinus node dysfunction or atrioventricular block.  No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X.  She recently had an ambulatory EEG.  I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  Reveal event monitor was considered, but not placed since she has only had one single episode.",IV Procainamide Infusion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,"
"Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.","PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.",Hysteroscopy & Endometrial Ablation,Obstetrics / Gynecology,"obstetrics / gynecology, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine,"
Stress test with Bruce protocol due to chest pain.,"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.,",Stress Test Bruce Protocol,Cardiovascular / Pulmonary,
Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands.   The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.,"NERVE CONDUCTION TESTING AND EMG EVALUATION,1.  Right median sensory response 3.0, amplitude 2.5, distance 100.,2.  Right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  Left median sensory response 3.0, amplitude 1.2, distance 100.,4.  Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1.  ,RIGHT BICEPS:,  Fibrillations 0, fasciculations occasional, positive waves 0.  Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,RIGHT TRICEPS:,  Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  Motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,EXTENSOR DIGITORUM:,  Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+.  Motor units, decreased number of motor units firing.,5.  ,RIGHT ABDUCTOR POLLICIS BREVIS:,  Fibrillations 1+, fasciculations 1+, positive waves 0.  Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:,  Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  Motor units, decreased number of motor units firing.,7.  ,LEFT FIRST DORSAL INTEROSSEOUS:,  Fibrillations 1+, fasciculations 1+, positive waves occasional.  Motor units, decreased number of motor units firing.,8.  ,LEFT EXTENSOR DIGITORUM:,  Fibrillations 1+, fasciculations 1+.  Motor units, decreased number of motor units firing.,9.  ,RIGHT VASTUS MEDIALIS:,  Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  Motor units, decreased number of motor units firing.,10.  ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  Motor units, increased proportion of polyphasic units and decreased number of motor units firing.  There is again increased needle insertional activity.,11.  ,RIGHT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 1+.  Motor units, marked decreased number of motor units firing.,12.  ,LEFT GASTROCNEMIUS:,  Fibrillations 1+, fasciculations 1+, positive waves 2+.  Motor units, marked decreased number of motor units firing.,13.  ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+.  Motor units, decreased number of motor units firing.,IMPRESSION:",EMG/Nerve Conduction Study - 10,Neurology,
Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia.,"CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.",Neck & Lower Back Pain - Consult,Orthopedic,
"Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.","CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.",Immunohistochemical Study,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,"
Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).,"CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.",Cerebral Angiogram,Neurology,
CT Scan of  brain without contrast.,"REASON FOR EXAMINATION:  Face asleep.,COMPARISON EXAMINATION:  None.,TECHNIQUE:  Multiple axial images were obtained of the brain.  5 mm sections were acquired.  2.5-mm sections were acquired without injection of intravenous contrast.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:  No acute intracranial abnormalities appreciated.  No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections.  No cortical based abnormalities appreciated.  The sinuses are clear.  No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION:  No acute intracranial abnormalities appreciated.,",CT Scan of  Brain w/o Contrast,Neurology,"neurology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities,"
"Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.","PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE:  ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route.  This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg.  The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventilation was commenced.  The patient was fully warm and the patient was then wean from cardiopulmonary bypass.  The patient was decannulated in 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 plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.",CABG - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary"
"Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.","PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.",Anterior Cervical Discectomy & Decompression,Neurosurgery,
"Umbilical hernia repair template.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.","PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.",Umbilical Hernia Repair,Gastroenterology,"gastroenterology, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,"
"Achilles tendon rupture, left lower extremity.  Primary repair left Achilles tendon.  The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.","PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.",Achilles Tendon Repair,Orthopedic,"orthopedic, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity"
"Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.","REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.",Malignant Meningioma - Consult,Neurology,"neurology, seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin"
A patient with non-Q-wave myocardial infarction.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,"REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  The patient reports having worsening emesis and emesis a few times.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus.,2.  Hypertension.,3.  Renal failure, on dialysis.,MEDICATIONS:,  Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General:  The patient denies fever or chills.  Pulmonary:  The patient denies hemoptysis.  Cardiovascular:  Refer to HPI.  GI:  The patient denies hematemesis or melena.  The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL:  A well-nourished, well-developed male in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils seem to be equal, round, and reactive.  Extraocular muscles are full, but the patient has left eye ptosis.,NECK:  Supple without JVD or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI is displaced 0.5 cm lateral to the midclavicular line.  Regular rate and rhythm, S1, S2.  No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN:  Positive bowel sounds, nondistended and nontender.  No hepatosplenomegaly.,EXTREMITIES:  Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  PT 11.3, INR 1.1, and PTT 24.1.  Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4.  CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6.  Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1.  Paroxysmal atrial fibrillation.  The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm.  The patient is currently in sinus rhythm.,2.  Emesis.  The etiology is unclear.  The patient reports that the emesis is better.  The patient is just having some nausea.,3.  Non-Q-wave myocardial infarction.  EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4.  Diabetes mellitus.,5.  Renal failure.,6.  Hypertension.,7.  Hypercholesterolemia.,PLAN:,1.  We will start amiodarone to keep from going back into atrial fibrillation.,2.  Echocardiogram.,3.  Aspirin and IV heparin.,4.  Serial CK-MB and troponin.,5.  Cardiac catheterization, possible percutaneous coronary intervention.  The risks, benefits, and alternatives were explained to the patient through a translator.  The patient understands and wishes to proceed.,6.  IV Integrilin.",Non-Q-wave Myocardial Infarction,Cardiovascular / Pulmonary,
"Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.","REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",Cervical Spinal Stenosis,Orthopedic,
Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,"INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.",Cardiac Consultation - 6,Cardiovascular / Pulmonary,
Normal upper GI endoscopy.,"INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.",Endoscopy Template,Gastroenterology,"gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope"
"Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.","GROSS DESCRIPTION: ,  Specimen labeled ""right ovarian cyst"" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,",Pathology - Ovarian Cyst,Obstetrics / Gynecology,"obstetrics / gynecology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Pediatric Gastroenterology - Rectal Bleeding Consult.,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",Rectal Bleeding - 1-year-old,Pediatrics - Neonatal,
"Rotated cuff tear, right shoulder.  Glenoid labrum tear.  Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.","PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Rotated cuff tear, right shoulder.,2.  Glenoid labrum tear.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic glenoid labrum debridement.,2.  Subacromial decompression.,3.  Rotator cuff repair, right shoulder.,SPECIFICATIONS:,  Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital.  This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  He was completely refractory to conservative outpatient therapy.  After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed.  There was noted to be a degenerative glenoid labrum tear.  The biceps complex was otherwise intact.  There were minimal degenerative changes at the glenohumeral joint.  Rotator cuff tear was appreciated on the inner surface.  Subacromially, the same was true.  This was an elliptical to V-type tear.  The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department.  He was safely placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  Debridement was carried out to the glenoid labrum.  The biceps was probed and noted to be intact.  Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed.  The scope was placed subacromially and a lateral portal created.  Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  An anterolateral portal was created.  Sutures were placed via express silk as well as other sutures with a #2 fiber wire.  With passing of the suture, they were tied with a slip-tight knot and then two half stitches.  There was excellent reduction of the tear.  Superolateral portal was then created.  A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  The implant was put into place.  The loop was grabbed and it was impacted in the previously drilled holes.  There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie.  A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint.  Gross bursectomy lightly was carried out to remove all bony elements.  A pain buster catheter was placed through a separate portal and cut to length.  0.5% Marcaine was instilled after portals were closed with #4-0 nylon.  Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing.  The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition.  Expected surgical prognosis of this patient is fair.",Arthroscopic Rotator Cuff Repair - 1,Orthopedic,"orthopedic, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,"
Wrist de Quervain stenosing tenosynovitis.  de Quervain release.  Fascial lengthening flap of the 1st dorsal compartment.,"PREOPERATIVE DIAGNOSIS:,  Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2.  Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid.  Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  I then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  The EPB subsheath was likewise released.,I irrigated the wound thoroughly.  In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position.  I did this with 3-0 Vicryl.  I then passed an instrument underneath to check and make sure that the sheath was not too tight.  I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.",de Quervain Release - Wrist,Orthopedic,"orthopedic, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,"
"Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient would benefit from skilled physical therapy intervention.","DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:,  The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease.  The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms.  The patient states that this occurred in October 2008 as well as November 2008.  The patient has a history of low back pain, secondary to a fall that originally occurred in 2006.  The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region.  The patient then had her second fall in March 2006.  The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:,  Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1.  TriCor.,2.  Vytorin.,3.  Estradiol.,4.  Levothyroxine.,5.  The patient is also taking ibuprofen 800 mg occasionally as needed for pain management.  The patient states she rarely takes this and does not like to take pain medication if at all possible.  The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:,  The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with.  The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption.  The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day.  However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain.  The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:,  The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation.  The patient states she is able to bring the report in upon next visit.,SUBJECTIVE:  ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse.  The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region.  Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects.  The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:,  The patient reports having occasional shooting pains into the lower extremities.  However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device.  However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity.  The patient does have mild difficulty transferring from the seated position to standing.  However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE:  ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5.  The patient denies any significant tenderness to palpation.  However, does have mild increase in tenderness on the right versus left.  A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking.  The patient was able to continue; however, stopped after 700 feet.  There were two minutes remaining in the six-minute walk test.  The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1.  Increased pain.,2.  Decreased ability to complete tasks and hobbies.,3",Physical Therapy - Back Pain,Orthopedic,
"Patient with hypertension, syncope, and spinal stenosis - for recheck.","SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.",Hypertension - Progress Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,"
"A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.","INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.",Paroxysmal Atrial Fibrillation,Cardiovascular / Pulmonary,
"This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.","INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL:",Neonatal Consult,Pediatrics - Neonatal,
"Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.","EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.",Cardiac Catheterization,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,"
"Dual chamber generator replacement.  The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.","REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.",Dual Chamber Generator Replacement,Cardiovascular / Pulmonary,
"Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.","PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.",Cemented Arthroplasty,Orthopedic,
This is a middle-aged female with two month history of low back pain and leg pain.,"FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:",CT Lumbar Spine - 2,Orthopedic,"orthopedic, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet"
Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings),"EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.",Full-Field Digital Mammogram (FFDM) - 1,Obstetrics / Gynecology,"obstetrics / gynecology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography"
"Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.","SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",Sports Physical - 4,Pediatrics - Neonatal,
"Chest pain,  Chest wall tenderness occurred with exercise.","INDICATIONS:,  Chest pain.,PROCEDURE DONE:,  Graded exercise treadmill stress test.,STRESS ECG RESULTS:,  The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol.  The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate.  The blood pressure increased from 120/70 to 130/80.  The baseline resting electrocardiogram reveals a regular sinus rhythm.  The tracing is within normal limits.  Symptoms of chest pain occurred with exercise.  The pain persisted during the recovery process and was aggravated by deep inspiration.  Marked chest wall tenderness noted.  There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1.  Stress test is negative for ischemia.,2.  Chest wall tenderness occurred with exercise.,3.  Blood pressure response to exercise is normal.",Stress Test Graded Exercise Treadmill,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest,"
"Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.  Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.","PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.",Arthroscopy & Chondroplasty,Orthopedic,"orthopedic, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral,"
"Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.","SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.",SOAP - Lung Mass,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,"
"Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.","CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.",Consult - Seizures - 1,Neurology,
"A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.","HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.",COPD - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,"
A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.,"CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.",CT Chest - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest,"
Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy.,"CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",Non-Hodgkin lymphoma Followup,Hematology - Oncology,
"Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy","HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.",Pulmonary Valve Stenosis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary,"
A 66-year-old female with knee osteoarthrosis who failed conservative management.,"PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,",Knee Osteoarthrosis - Discharge Summary,Orthopedic,"orthopedic, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee,"
"Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.","PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.",Anterior Cervical Discectomy & Fusion - 2,Orthopedic,"orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior"
Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,"PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.",Hemilaminotomy & Foraminotomy,Orthopedic,"orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,"
Patient reports a six to eight-week history of balance problems with later fatigue and weakness.,"HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was ""rebuilt."" He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, ""natural"" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.",Cervical Cord Lesion - Consult,Neurology,
"Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.","ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.",Knee Arthroplasty - Discharge Summary,Orthopedic,"orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,"
Patient with stable expressive aphasia and decreased vision.,"CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.",Multiple Meningiomas,Neurology,"neurology, sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Thallium stress test for chest pain.,"INDICATIONS:  ,Chest pain.,STRESS TECHNIQUE:,",Stress Test Thallium,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress"
"Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder.  Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.","PREOPERATIVE DIAGNOSIS:,  Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Massive rotator cuff tear, right shoulder.,2.  Near complete biceps tendon tear, right shoulder.,3.  Chondromalacia of glenohumeral joint, right shoulder.,4.  Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED:  ,1.  Arthroscopy of the arthroscopic glenoid labrum.,2.  Rotator cuff debridement shaving glenoid and humeral head.,3.  Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed.  He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention.  This was gradually done over a period of time.  No specific accident or injury could be seen or pointed.  He was refractory to conservative outpatient therapy.  After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion.  He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated.  His rotator interval was resolved as well as his subscapularis with tearing.  The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe.  Glenoid labrum had degenerative tear in the inferior surface.  Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position.  He was prepped and draped in the usual sterile manner.  The portals were created outside the end posteriorly and then anteriorly.  A full and complete diagnostic arthroscopy was carried out with the above-noted findings.  The shaver was placed anteriorly.  Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed.  Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out.  Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity.  No osteophytes were present.  Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring.  There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this.  We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly.  We took this back to the level of coracoid base.  We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn.  Because of this, further debridement was carried out.  Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge.  Care was taken to not to debride deeper than that.  This was done prior to the above.,All instrumentation was removed.  A Pain-Buster catheter was placed into a separate anterolateral portal cut to length.  Interrupted #4-0 nylon was utilized for portal closures.  Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling.  He was transferred to his cart and to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.",Arthroscopy - Glenoid Labrum,Orthopedic,"orthopedic, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff,"
"Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.","REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.",Cardiac Transfer Summary,Cardiovascular / Pulmonary,
Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome.,"PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.","Heart Catheterization, Ventriculography, & Angiography - 9",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,"
A patient with non-Q-wave myocardial infarction.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,"REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  The patient reports having worsening emesis and emesis a few times.  No definite chest pains.  The patient is breathing okay.  The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus.,2.  Hypertension.,3.  Renal failure, on dialysis.,MEDICATIONS:,  Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General:  The patient denies fever or chills.  Pulmonary:  The patient denies hemoptysis.  Cardiovascular:  Refer to HPI.  GI:  The patient denies hematemesis or melena.  The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL:  A well-nourished, well-developed male in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils seem to be equal, round, and reactive.  Extraocular muscles are full, but the patient has left eye ptosis.,NECK:  Supple without JVD or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI is displaced 0.5 cm lateral to the midclavicular line.  Regular rate and rhythm, S1, S2.  No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN:  Positive bowel sounds, nondistended and nontender.  No hepatosplenomegaly.,EXTREMITIES:  Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  PT 11.3, INR 1.1, and PTT 24.1.  Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4.  CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6.  Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1.  Paroxysmal atrial fibrillation.  The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm.  The patient is currently in sinus rhythm.,2.  Emesis.  The etiology is unclear.  The patient reports that the emesis is better.  The patient is just having some nausea.,3.  Non-Q-wave myocardial infarction.  EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4.  Diabetes mellitus.,5.  Renal failure.,6.  Hypertension.,7.  Hypercholesterolemia.,PLAN:,1.  We will start amiodarone to keep from going back into atrial fibrillation.,2.  Echocardiogram.,3.  Aspirin and IV heparin.,4.  Serial CK-MB and troponin.,5.  Cardiac catheterization, possible percutaneous coronary intervention.  The risks, benefits, and alternatives were explained to the patient through a translator.  The patient understands and wishes to proceed.,6.  IV Integrilin.",Non-Q-wave Myocardial Infarction,Cardiovascular / Pulmonary,
"Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.","PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.",Nerve & Tendon Repair - Finger,Neurosurgery,"neurosurgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,"
"He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again.","HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , 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:  BP 124/77",Diplopia,Ophthalmology,
"Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.","REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",Lung Cancer & MI - Hospice Cosult,Hematology - Oncology,
"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.","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.",Transthoracic Echocardiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic"
Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.,"PREOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:,  General.,FINDINGS:,  The gallbladder was thickened and showed evidence of chronic cholecystitis.  There was a great deal of inflammatory reaction around the cystic duct.  The cystic duct was slightly larger.  There was a stone impacted in the cystic duct with the gallbladder.  The gallbladder contained numerous stones which were small.  With the stone impacted in the cystic duct, it was felt that probably none were within the common duct.  Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:,  Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully.  Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out.  This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct.  In this manner, the cystic duct and cystic artery were dissected out.  Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct.  The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct.  The gallbladder was then dissected free from the gallbladder bed.  Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction.  The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding.  The gallbladder was extracted through the operating trocar site, and the trocar was reinserted.  Inspection was made of the gallbladder bed.  One or two bleeding areas were fulgurated, and bleeding was well controlled.",Laparoscopic Cholecystectomy - 2,Gastroenterology,"gastroenterology, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory"
"Torn lateral meniscus and chondromalacia of the patella, right knee.  Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.","PREOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1.  Arthroscopic lateral meniscoplasty.,2.  Patellar shaving of the right knee.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:,  Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain.  He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE:  ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position.  Department of Anesthesia administered general anesthetic to the patient.  All bony prominences were well padded at this time.  The right lower extremity was then properly positioned in a Johnson knee holder.  At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  The right lower extremity was then sterilely prepped and draped in usual sterile fashion.  Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  The cannula and trocar were then inserted through this, putting the patellofemoral joint.  An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella.  There were no loose bodies noted in the either gutter.  Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  While in this area, attention was directed to establish the inferomedial instrument portal.  This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  A probe was then inserted through this portal and the meniscus was further probed.  Again, there was noted to be no meniscal tear.  The knee was taken through range of motion and there was no chondromalacia.  Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign.  PCL was also noted to be intact.  Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus.  It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  Pictures were taken both pre-meniscal resection and post-meniscal resection.  The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  Next, attention was directed to the inner surface of the patella.  This was debrided using the 2.5 arthroscopic shaver.  It was noted to be quite smooth and postprocedure the patient was taken ________ well.  The knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity.  At this time, Department of Anesthesia reversed the anesthetic.  The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure and there were no complications.",Arthroscopic Meniscoplasty,Orthopedic,"orthopedic, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus,"
"Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.","PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1.  Left carpal tunnel release (64721).,2.  Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3.  Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic.  He is also has end-stage renal failure and has chronic hemodialysis.  Additionally, the patient has had prior heart transplantation.  He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity.  However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger.  These started initially as unrecognized paper cuts.  Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger.  Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger.  Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary.  Thirdly, this patient does have chronic distal ischemic problems with evidence of ""ping-pong ball sign"" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers.  However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks.  Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve.  This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef.  The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion.  A sterile tourniquet and webril are placed higher on the arm.  The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg.  I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease.  Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal.  I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm.  Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel.  The synovium was somewhat thickened, but not unduly so.  There was some erythema along the length of the median nerve, indicating chronic compression.  The motor branch of the median nerve was clearly identified.  The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified.  The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle.  Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass.  In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap.  I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm.  The entire medial intramuscular septum is now excised.  The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures.  Larger penetrating vascular tributaries to the muscle ligated between hemoclips.  I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers.  The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques.  In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner.  Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other.  So that in effect a lengthening is performed.  Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures.  I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve.  The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis.  Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound.  A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin.  A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist.  Fingers and femoral were free to move.  The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage.  Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition.  Sponge and needle counts reported as correct at the end of the procedure.",Carpal Tunnel Release - 3,Orthopedic,"orthopedic, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm,"
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.,"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.",Atrial Fibrillation - Consult,Cardiovascular / Pulmonary,
"Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.","FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.",Anterior Cervical Discectomy & Fusion - Discharge Summary,Neurosurgery,"neurosurgery, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,"
A female with unknown gestational age who presents to the ED after a suicide attempt.,"The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,",Consult/ER Report - OB/GYN,Obstetrics / Gynecology,
"Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.","REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",Cervical Spinal Stenosis,Neurology,
Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion.,"PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.",Salpingooophorectomy - Laparoscopic,Obstetrics / Gynecology,
"Motor vehicle collision.  CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.","CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.","CT Head, Facial Bones, Cervical Spine - 1",Orthopedic,"orthopedic, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones,"
"Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".","CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.",Lung adenocarcinoma Path Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,"
Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,"POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.",Bronchoalveolar lavage.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.,"PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.",Heart Cath & Coronary Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,"
Initial evaulation - neck and back pain.,"CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed ""sciatica"" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.",Neck & Back Pain,Orthopedic,
"Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.","SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain.  She has a history of prior laminectomy for spinal stenosis.  She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic.  Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005.  She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip.  An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  Dr. XYZ had performed right intraarticular hip injection on 04/07/2005.  She was last seen on 04/15/2005.  At that time, she had the hip injection that helped her briefly with her pain.  She is not sure whether or not she wants to proceed with hip replacement.  We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today.  She continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her.  She is taking Ultracet or other the generic it sounds like, up to four times daily.  She states she can take this much more frequently as she still has significant pain symptoms.  She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:,  Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 4 inches.  Weight is 149 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows lumbar scoliosis with surgical scar with no major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Degenerative disk disease of the right hip, symptomatic.,2.  Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3.  Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  Facet and sacroiliac joint syndrome on the right, stable.,5.  Post left hip arthroplasty.,6.  Chronic pain syndrome.,RECOMMENDATIONS:,  The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  In the interim, her Ultracet is not quite taking care of her pain.  I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day.  I have written a prescription for this for 120 tablets and two refills.  The patient will call for the refills when she needs them.  I will plan further follow up in six months, sooner if needed.  She voiced understanding and is in agreement with this plan.  Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings.",Orthopedic Consult - 2,Orthopedic,"orthopedic, scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lumbar scoliosis, injections, hip,"
Right heart catheterization.   Refractory CHF to maximum medical therapy.,"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.",Heart Catheterization - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy"
Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema.,"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 Change,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator"
Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement.,"ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.",Gastrointestinal Bleed - ER Visit,Gastroenterology,
"Psychiatric evaluation for ADHD, combined type.","IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr.  Circumstances leading to this admission:  In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h.  Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper.  ABCD is also complaining of headaches when he takes the medication.  Mother reports that on the weekends he is off the medication.  She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, ""It's an accident.""  She sees him as impulsive on the weekends, but is not sure if this just isn't ""all boy."",Mother reports ABCD has been on medication since kindergarten.  Currently, the teachers say he is able to pay attention and he is well behaved in school.  Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct.  He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep:  As stated before, he is having much difficulty on a consistent basis falling asleep.  It is 12:00 to 1:00 a.m. before he falls to sleep.  When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty.  On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite:  He will eat breakfast and supper, but not much lunch, if any at all.  He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control:  Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior.  The only exception to this is he gets in occasional fights with his sisters.  ABCD denies visual or auditory hallucinations or racing thoughts.  He reports his thoughts are sometimes bad because he says sometimes he thinks of the ""S"" word.,Energy:  Mother reports a lot of energy.,Pain:  ABCD denies any pain in his body.,Suicidal or homicidal thoughts:  He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06.  He has received outpatient therapy from XYZ, LCSW.  He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar.  She reports she has significant moodiness episodes and believes in the past she has had a manic episode.  She is currently not on medication.  She does not know of anyone else in her family, with the exception of she said her father's behavior was ""weird.""  Biological father's side of the family, mother reports father was very impulsive.  He had anger issues.  He had drug and alcohol issues.  He was in jail for three years for risky behavior.  There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years.  They divorced when ABCD was 2-1/2 years of age.  Currently, father has been deported back to Mexico.  He last saw ABCD in March 2006 for one day when they went down to AAAA.  He does call on special holidays and his birthday.  Contact is brief, but so far has been consistent.  Mother is currently seeing R, a significant other, and has been seeing him for the last seven months.  ABCD had a good relationship with R.  ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as ""all wisdom."",PREGNANCY:,  Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero.  She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:,  Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:,  Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:,  Mother reports ABCD was a very cuddly infant and could sleep well.  As a toddler, he was all over the place, climbing and always busy.  Elementary school:  In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen.  ABCD has no history of fire setting or abuse to animals.  He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:,  Noncontributory.,MEDICAL STATUS AND HISTORY:,  ABCD has no known drug allergies.  He has no history of heart murmur, heart defect of other heart problems.  No history of asthma, seizures or head injuries.  He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:,  When I asked ABCD whether he likes school, he stated, ""No.""  His grades are okay, per mother.  He does have an IEP for the ADHD, but she does not believe he has a learning disability.  Behavior problems:  He currently is not having any behavior problems in the school.  He reports he does not get along with his teachers because they tell him what to do.  Strengths:  He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:,  He reports he has best friends.  He named two, D and B, and he does have a friend that is a girl named Kim.  When asked if church or God were important to him, he stated, ""God is.""  He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:,  In the home, he has chores of taking out the trash.,LEGAL:,  He has not been involved in the legal system.,SUPPORT SYSTEMS:,  When asked if he feels safe in his home, he stated, ""Yes.""  When asked who he talks to if he is hurt or upset, he stated, ""Mom.""  (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:,  He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:,  This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions.  ABCD kept himself occupied throughout and was very well behaved throughout the session.  He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes.  Distractibility and attention:  He, at times, was very mildly distracted, but otherwise did not appear hyperactive.  His judgment was adequate.  When asked what he would do if there was a fire in his house, he said, ""Get out!""  Insight was poor to adequate.  Fund of information was good.  When asked who the president was, he said, ""George Washington."" Intelligence is probably average to above average.  Speech was normal.  He had some difficulty with abstract thinking.  He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle.  On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly.  When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly.  Appearance was casual.  Hygiene was good.  Attitude was cooperative.  Speech was normal.  Psychomotor was between normal and slightly hyperactive.  Orientation was x2.  Attention/concentration was intact.  Memory was intact at times and then had some memory recall problems with three words.  Mood was euthymic.  Affect was bright.  He has no suicidal or homicidal/violence risks.  Perceptions were normal.  Thought process logical.  Thought content normal.  Disassociation none.  Sleep:  He is having some insomnia.  Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:,  He has a strong support system in his mother, grandmother, and mother's significant other, Richard.  He has good health.  He has shown gain from past treatment.  He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.",Psychiatric Evaluation - 3,Psychiatry / Psychology,
Direct laryngoscopy and bronchoscopy.,"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.",Direct Laryngoscopy,ENT - Otolaryngology,"ent - otolaryngology, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,"
"Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.","PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.",Lumbar Puncture - 2,Orthopedic,"orthopedic, spinal needle, lumbar puncture, lumbar, gauge, csf"
"Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.","REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.",Azotemia Consult,Nephrology,"nephrology, urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary,"
"Headache, improved.  Intracranial aneurysm.","CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.",Intracranial aneurysm - ER Visit,Neurology,"neurology, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial,"
"Exercise stress test with nuclear scan for chest pain.  Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product.  Normal nuclear myocardial perfusion scan.","INDICATION:  ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60.  EKG normal sinus rhythm.  The patient exercised on Bruce for 8 minutes on stage III.  Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54.  Total METs was 10.1.  EKG revealed nonspecific ST depression in inferior and lateral leads.  The test was terminated because of fatigue.  The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1.  Positive exercise ischemia with ST depression 0.5 mm.,2.  Chest pain resolved after termination of exercise.,3.  Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 68%.  End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction of 68% by gated SPECT.",Exercise Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest"
Consultation for an ASCUS Pap smear.,"Pap smear in November 2006 showed atypical squamous cells of undetermined significance.  She has a history of an abnormal Pap smear.  At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia.  She underwent a cone biopsy that per her report was negative for any pathology.  She had no vulvar treatment at that time.  Since that time, she has had normal Pap smears.  She denies abnormal vaginal bleeding, discharge, or pain.  She uses Yaz for birth control.  She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis.  She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections.  She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B.  She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX:  ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use.  He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:,  She is a public relations consultant.  She is a nonsmoker, drinks infrequent alcohol and does not use drugs.  She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches.  Weight: 139 lb.  BMI: 22.4.  Blood Pressure: 102/58.  GENERAL: She is well-developed and well-nourished with normal habitus and no deformities.  She is alert and oriented to time, place, and person and her mood and affect is normal.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  BREASTS: Deferred.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Normal external female genitalia.  Vulva, vagina, and urethra, within normal limits.  Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance.  GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid.  This shows an entirely normal transformation zone, so no biopsies are taken.  An endocervical curettage is then performed with Cytobrush and curette and sent to pathology.  Colposcopy of the vulva is then performed again with acetic acid.  There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter.  There are absolutely no abnormal vessels within this area.  The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV.  We will check the results of the ECC.  She will return in two weeks for test results.  If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.",OB/GYN Consultation - 3,Obstetrics / Gynecology,"obstetrics / gynecology, lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,"
"Repeat low-transverse cesarean section via Pfannenstiel incision.  Intrauterine pregnancy at 39 and 1/7th weeks.  Previous cesarean section, refuses trial of labor.  Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:,  Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  1200 cc.,FLUIDS:,  2700 cc.,URINE:,  400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS:  ,Placenta, cord gases and cord blood.,INDICATIONS:  ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions.  She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm.  A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally.  There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained.  The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery.  She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this.  After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered.  She was then prepped and draped in the normal sterile fashion.  Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered.  Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife.  The fascia was incised in the midline with a second knife.  This incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps.  It was then dissected in the midline with Mayo scissors.  The inferior aspect of this incision was then addressed in a similar manner.  The rectus muscles were then separated in the midline with a hemostat.  The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly.  Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors.  This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly.  Next, the bladder blade was placed.  The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors.  This incision was extended laterally in both directions and a bladder flap was created digitally.  The bladder blade was then reinserted.  Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife.  Next, the uterine incision was extended laterally in both directions with the banded scissors.  Next, the infant's head and body were delivered without difficulty.  There was multiple section on the abdomen.  The cord was clamped and cut.  Section of cord was collected for gases and the cord blood was collected.  Next, the placenta was manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The edges of the uterine incision were then identified with Allis _______ clamps.  The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis.  One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid.  After several minutes of observation, the hematoma was seem to be non-expanding.  The uterus was replaced in the abdomen.  The uterine incision was reexamined and seem to be continuing to be hemostatic.  The pelvic gutters were then cleared of all clots and debris.  The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion.  The peritoneum was then closed with #0 Vicryl in a running fashion.  The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch.  The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x3.  The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.",Low-Transverse C-Section - 8,Obstetrics / Gynecology,
"Flexor carpi radialis and palmaris longus repair.  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.","PREOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:,  Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,PROCEDURES PERFORMED:  ,1.  Repair flexor carpi radialis.,2.  Repair palmaris longus.,ANESTHETIC: , General.,TOURNIQUET TIME:  ,Less than 30 minutes.,CLINICAL NOTE:  ,The patient is a 21-year-old who sustained a clean laceration off a teapot last night.  She had lacerated her flexor carpi radialis completely and 90% of her palmaris longus.  Both were repaired proximal to the carpal tunnel.  The postoperative plans are for a dorsal splint and early range of motion passive and active assist.  The wrist will be at approximately 30 degrees of flexion.  The MPJ is at 30 degrees of flexion, the IP straight.  Splinting will be used until the 4-week postoperative point.,PROCEDURE: , Under satisfactory general anesthesia, the right upper extremity was prepped and draped in the usual fashion.  There were 2 transverse lacerations.  Through the first laceration, the flexor carpi radialis was completely severed.  The proximal end was found with a tendon retriever.  The distal end was just beneath the subcutaneous tissue.,A primary core stitch was used with a Kessler stitch.  This was with 4-0 FiberWire.  A second core stitch was placed, again using 4-0 FiberWire.  The repair was oversewn with locking, running, 6-0 Prolene stitch.  Through the second incision, the palmaris longus was seen to be approximately 90% severed.  It was an oblique laceration.  It was repaired with a 4-0 FiberWire core stitch and with a Kessler-type stitch.  A secure repair was obtained.  She was dorsiflexed to 75 degrees of wrist extension without rupture of the repair.  The fascia was released proximally and distally to give her more room for excursion of the repair.,The tourniquet was dropped, bleeders were cauterized.  Closure was routine with interrupted 5-0 nylon.  A bulky hand dressing as well as a dorsal splint with the wrist MPJ and IP as noted.  The splint was dorsal.  The patient was sent to the recovery room in good condition.",Flexor Carpi Radialis & Palmaris Longus Repair,Orthopedic,"orthopedic, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair"
Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.",Pulmonary - Followup Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary,"
Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.,"IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself.  She was formerly seen at Counseling Center.  She is a reliable historian.,CHIEF COMPLAINT:,  ""I'm bipolar and I have severe anxiety disorder.  I have posttraumatic stress syndrome."" ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc had a recurrence of memories.  Her father had molested her, and the memories returned.  In 1992, at the age of 18, she entered her first abusive marriage.  She was beaten and her husband shared her sexually with his friends.  This lasted until age 24.  The second marriage was age 26, her second husband was a drug abuser and ""he slapped me around.""  She had two children during that marriage.  In 2001, she was married in Indiana to a military man.  This was her third marriage and she stated, ""This marriage is good.""  She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder.  ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage.  Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have.  Currently, she is unable to have sex with the lights on.  She states, ""Sometimes I hurt all over.""  Her husband was deployed three days ago, on April 21, to a foreign theater of operations.  She has panic attacks every day.,Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave.  She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements.  She is not unable to recall details of her trauma.  She does feel detached and isolated.  She has restrictive range of affect and she had a foreshortened future.  She also had a loss of interest in things, starting at age 5.  She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, ""I don't do as good as I can.""  Further review of symptoms shows her to have periods of constant cleaning and increased sex drive.  She also has had euphoria, poor judgment, distractibility, and inability to concentrate.  She has been irritable.  She has had a decreased need for sleep, which lasts for six or seven days.  She had racing thoughts, rapid speech, but has not had grandiosity.  These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized.  Furthermore, she endorses the following symptoms:  She states, ""When I'm depressed, I have neck pain, jaw pain, abdominal pain.  I have migraines and urinary tract pain.""  She also complains of chest pain, pain during sex, and excess pain during her menstrual period.  She has an increased gag reflex, which has caused her to have emesis.  She states it is easy to choke.  She has had physical symptoms, ""for as long as I can remember,"" and she states, ""I've felt like crap most of my life,""  ""it affects my marriage.""  She has also admitted to having nausea and vomiting, with excess gas.  She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea.  She states that sex is only important to her in mania.  Otherwise, she has no desire.  She has had irregular periods for two or three weeks at a time.  She has had no episodes of excess bleeding.  She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion.  Currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of Lunesta.  Her energy is ""not good.  Her appetite is ""I'm craving crap,"" stating that she wants to eat carbohydrates.  Concentration is poor today.  She feels worthless, hopeless, and guilty.  Her self-esteem is ""I don't have any.""  She has no anhedonia, and she has no libido.  She also has had feelings of chronic emptiness.  She feels abandoned.  She has had unstable relationships.  She self-mutilated, but she stopped at age 22.  She has trouble controlling her anger.  She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child.  She has no identity disturbance.  ,CURRENT MEDICATIONS: , Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown.  In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: , She saw Dr. B.  She saw Chris.  She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder.  She had counseling in Indiana in 2001.  She had inpatient treatment in Indiana in 2001 also, at age 19.  She had three suicide attempts.  At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more.  She has had no psychological testing.  ,MEDICAL HISTORY: , Significant for migraines, hyperactive and gag reflex.  She states she has had cardiovascular workups due to panic disorder, but nothing was found.  She also has astigmatism.  She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy.  She has no history of head injury or MRI test of the brain.  No history of EEG, seizures, thyroid problems, or asthma.  There are no drug allergies.  She has never had an EKG.  She does have musculoskeletal problems and has arthritis-like joint pains on occasion.  She has had ear infections and sinus infections intermittently.  Hearing test was normal.  She is currently not pregnant.  She saw her gynecologist four months ago at Elmendorf Air Force Base.  ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19.  She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown.  ,She has no hypertension, no diabetes, no glaucoma.,FAMILY HISTORY: , Significant for her paternal grandmother not being mentally competent.  Her mother was depressed and was treated.  Her mother is currently age 55.  She has a paternal grandmother who may have had Schizophrenia.  There is also a family history of the paternal grandfather using substance.  He was ""an extreme alcoholic.""  She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess.  The maternal uncle committed suicide; he drowned himself.  ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out.  Her mother and two maternal aunts have thyroid disease.  She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer.  There is no family history of hypertension.,ABUSE HISTORY: , Significant for being physically abused by her father, her first husband, and her second husband.  She was sexually abused by her father from age 5 to age 18.  She states, ""my first husband gave me away for four years to his friends to be used sexually.""  She was emotionally abused by her mother, father, and both of her first two husbands.  She was neglected by her mother and her father.  She never witnessed domestic violence.  She has not witnessed traumatic events.  ,SUBSTANCE ABUSE: , Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early.  She has never used alcohol, tobacco, marijuana, or any other drugs.,PARENT/SIBLING RELATIONSHIP INFORMATION: , She had had a poor relationship with her parents.  She has no contact with them.  She has no contact with her brother.  She was married three times, as stated in the history.  She has two children with Asperger's and autism.  ,HOBBIES/SPIRITUAL: , She likes to read and write.  She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage.  ,EDUCATIONAL:,  She states she was teased in school because ""I was so depressed.""  She got good grades otherwise.  She finished high school.,WORK HISTORY:,  She has worked in the past managing a Dollar General store.  She has been a waitress and an executive secretary.  ,LEGAL HISTORY:,  She has never been arrested.,MENTAL STATUS:,  Significant for a well groomed, well kempt young white female who appears her stated age.  She has a pierced nose and has a nose ring.  She is cooperative, alert, and attentive.  She makes good eye contact.  Her speech is normal, prosody is normal, and rate and rhythm are normal.  Motor is normal.  She has no gait abnormalities.  No psychomotor retardation or agitation.  Her mood is ""I'm sad and depressed.""  Her affect is restricted.  She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews.  Perception is normal.  She denies auditory and visual hallucinations.  She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred.  Otherwise, she has not had dissociative phenomena.  Thought processes are normal.  She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality.  She is goal directed and oriented.  Insight and judgment are good.  She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring.  She is able to register three words and recall them at five minutes.  She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels.  She is given a proverb to interpret.  She was asked what judging a book by its cover meant.  She said, ""You can't always tell what a person is by looking at them on the outside.""  She is appropriate in her abstraction, and is able to identify the last four presidents.,CLINICAL IMPRESSION:  ,Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis.  She has had an extensive history of sexual abuse and emotional abuse.  She has not used drugs and alcohol, and she has been treated in the past.  She was treated with EMDR and stated that she did not benefit from that.  She has an extensive medical history and brought her medical records, and they were thoroughly reviewed.  She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005.  She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania.  Medical records review a history of dysmenorrhea with surgery to the right cystic ovary.  The EMDR did not benefit her in the past.  She also has not had good psychotherapeutic consultation.  ,DIAGNOSES:,AXIS  I.  309.81  Posttraumatic Stress Disorder.",Psychiatric Assessment,Psychiatry / Psychology,
MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.",MRI Brain & Cerebral Angiogram,Neurology,
"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.","PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.","Laminotomy, Facetectomy & Foraminotomy",Neurosurgery,"neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle"
"A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.","HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.",Cardiac Consultation,Cardiovascular / Pulmonary,
"Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.","REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization.  He has also been seen by me in the clinic in the last few weeks.  He was admitted on January 18, 2008, with recurrent malignant pleural effusion.  On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X.  He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  His hospital course here has been significant for dyspnea, requiring ICU stay.  He also had a chest tube, which was taken out few days ago.  He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31.  Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  He does have edema in his lower extremities.  He is currently on 4L of oxygen.  He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  No neurological or musculoskeletal signs or symptoms.  He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  He denies any other complaints.,PAST MEDICAL HISTORY:,  Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital.  History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:,  No known drug allergies.,CURRENT MEDICATIONS:  ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse.  He has history of tobacco smoking and also reports history of alcohol abuse.  No history of illicit drug abuse.,FAMILY HISTORY:  ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above.  He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL:  He is awake, alert, in no acute distress.  He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS:  Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT:  No icterus or sinus tenderness.  Oral mucosa is moist.,NECK:  Supple.  No lymphadenopathy.,LUNGS:  Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR:  S1 and S2 normal.,ABDOMEN:  Soft, nondistended, and nontender.  No hepatosplenomegaly.  Bowel sounds are present in all four quadrants.,EXTREMITIES:  Bilateral pedal edema is present in both the extremities.  No signs of DVT.,NEUROLOGICAL:  Grossly nonfocal.,INVESTIGATION:,  Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9.  Liver enzymes checked on January 17, 2008, were unremarkable.  CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1.  Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  Chronic obstructive pulmonary disease.,3.  Paroxysmal atrial fibrillation.,4.  Malignant pleural effusion, status post surgery as stated above.,5.  Anemia of chronic disease.,RECOMMENDATIONS,1.  Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides.  I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital.  I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2.  I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3.  Once the results of the above are available, I will make further recommendations regarding treatment.  The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4.  Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  They clearly understand the above.  They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.",Mesothelioma - Consult,Cardiovascular / Pulmonary,
Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation,"HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.",Cardioversion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,"
Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,"DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.",COPD & Bronchitis - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,"
"Repair of left ear laceration deformity Y-V plasty 2 cm.  Repair of right ear laceration deformity, complex repair 2 cm.","PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.",Ear Laceration Repair,ENT - Otolaryngology,"ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair"
A 51-year-old male with chest pain and history of coronary artery disease.,"COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.",Coronary CT Angiography (CCTA) - 4,Cardiovascular / Pulmonary,
Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.,"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.",Tesio Hemodialysis Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.","CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9"", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",Knee DJD - Consult,Orthopedic,
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.,"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.",Subxiphoid Pericardial Window - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,"
"A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.","HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",Complex Cyanotic Congenital Heart Disease,Cardiovascular / Pulmonary,
"VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.","PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.",Lobectomy - VATS,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,"
"Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.","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.",Stenting,Cardiovascular / Pulmonary,
Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration.,"PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,",Breast Mass Excision,Obstetrics / Gynecology,"obstetrics / gynecology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,"
"Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.","INDICATION: ,  Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE:  ,",Colonoscopy - 1,Gastroenterology,"gastroenterology, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory"
"MRI of the Cervical, Thoracic, and Lumbar Spine","INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  MRI of the thoracic spine showed normal vertebral body height and alignment.  There was evidence of disc generation, especially anteriorly at the T5-T6 level.  There was no significant central canal or foraminal compromise.  Thoracic cord normal in signal morphology.  MRI of the lumbar spine showed normal vertebral body height and alignment.  There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4.  There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess.  The transversing nerve root on the right was impinged at that level.  The right foramen was mildly compromised.  There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  This was also seen on a prior study.,",MRI Spine,Neurology,"neurology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Template for History and Physical for a newborn.,"HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,",Normal Newborn H&P Template,Pediatrics - Neonatal,
Persistent left hip pain.  Left hip avascular necrosis.  Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing,"CHIEF COMPLAINT:,",Hip Pain,Orthopedic,"orthopedic, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn,"
"Abnormal cardiac enzyme profile.  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.","REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",Elevated Cardiac Enzymes,Cardiovascular / Pulmonary,
"A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.","IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , ""I'm here because I'm different."" The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.",Psych Consult - Bipolar Affective Disorder,Psychiatry / Psychology,
"A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.","REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.",Rectal Bleeding - Consult,Gastroenterology,
"Congestion, tactile temperature.","CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",Congestion - 21-day-old,Pediatrics - Neonatal,
The patient is status post C3-C4 anterior cervical discectomy and fusion.,"She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies.",EMG/Nerve Conduction Study - 5,Neurology,"neurology, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve,"
"Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs","PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.","Discectomy, Osteophytectomy, & Foraminotomy",Neurosurgery,
Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura.,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",Hematoma Evacuation,Neurology,
Sample for Neuropsychological Evaluation,"REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.",Neuropsychological Evaluation - 1,Neurology,"neurology, neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis,"
Status post brain tumor removal.   The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  She had a brain tumor removed and had left-sided weakness.,"DIAGNOSIS:,  Status post brain tumor removal.,HISTORY:,  The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  The patient reports that she was admitted to Hospital on 12/05/08.  At that time, they found massive swelling on the brain and a second surgery was performed.  The patient then remained in acute rehab until she was discharged to home on 01/05/09.  The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS:  ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time.  The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL:  ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION:  Bilateral lower extremities are within normal limits.,STRENGTH:  Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE:  The patient's balance was assessed with a Berg balance test.  The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT:  The patient ambulates with contact guard assist.  The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  However, the patient has been reports that with increased fatigue, left footdrop tends to occur.  A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery.  Examination indicates deficits in strength, balance, and ambulation.  The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  Interventions include:,1.  Therapeutic exercise.,2.  Balance training.,3.  Gait training.,4.  Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1.  The patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  The patient is to improve balance with a score of 50/56 points.,3.  The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to ambulate independently within her home and standby to general supervision within the community.,2.  Berg balance test to be 52/56.,3.  The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good.  The above treatment plan has been discussed with the patient and her husband.  They are in agreement.",Physical Therapy - Brain Tumor Removal,Neurology,
Back injury with RLE radicular symptoms.  The patient is a 52-year-old male who is here for independent medical evaluation.,"PAST MEDICAL CONDITION:,  None.,ALLERGIES:,  None.,CURRENT MEDICATION:,  Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:,  The patient is a 52-year-old male who is here for independent medical evaluation.  The patient states that he works for ABC ABC as a temporary worker.  He worked for ABCD too.  The patient's main job was loading and unloading furniture and appliances for the home.  The patient was approximately there for about two and a half weeks.  Date of injury occurred back in October.  The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load.  Unfortunately at this particular event, the patient had sharp pain in his lower back.  Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee.  This became progressively worse.  He also states that some of his radiating pain went down to his left leg as well.  He noticed increase in buttock spasm and also noticed spasm in his buttocks.  He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe.  The patient states that after this treatment, his symptoms still persisted.  At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April.  After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids.  He was put on restricted duty.  The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral.  The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief.  The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD.  The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping.  He has difficulty sleeping at nighttime because of increase in pain.  Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June.  The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side.  The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:,  The patient was examined with the gown on.  Lumbar flexion was moderately decreased.  Extension was normal.  Side bending to the right was decreased.  Side bending to the left was within normal limits.  Rotation and extension to the right side was causing increasing pain.  Extension and side bending to the left was within normal limits without significant pain on the left side.  While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°.  There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position.  In supine position, straight leg was negative in the LLE and also negative on the RLE.  Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits.  Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side.  Medial hamstring reflex was 2+/4 on both hamstrings as well.  On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side.  Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:,  I had the opportunity to review Dr. XYZ's medical records.  Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December.  Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal.  The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:,  The patient has an impairment based on AMA Guides Fifth Edition and it is permanent.  The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck.  Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left.  The patient also has increase in back pain with lumbar flexion and rotational movement to the right side.  With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function.  Therefore, the patient is assigned 8% impairment of the whole person.  We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide.  Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury.  In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy.  The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI.  In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back.  His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain.  The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management.  The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,",Back Injury IME,Orthopedic,"orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,"
Ultrasound Abdomen - elevated liver function tests.,"EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed.  There is dilatation of the common bile duct up to 1 cm.  There is also dilatation of the pancreatic duct that measures up to 3 mm.  There is caliectasis in the right kidney.  The bladder is significantly distended measuring 937 cc in volume.  The caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  The aorta is normal in caliber., ,IMPRESSION:,1.  Dilated common duct as well as pancreatic duct as described.  Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass.  The findings could reflect changes of cholecystectomy.  ,2.  Significantly distended bladder with probably resultant caliectasis in the right kidney.  Clinical correlation recommended.",Ultrasound - Abdomen - 1,Gastroenterology,"gastroenterology, aorta, dilated common duct, mrcp, ercp, elevated liver function tests, pancreatic duct, distended bladder, ultrasound abdomen, cholecystectomy, ultrasound, abdomen, liver, dilatation, caliectasis, kidney, bladder, duct"
"The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.","REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.  She reports she is still having right posterior head pressure like sensations approximately one time per week.  These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair.  This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve.  Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television.  She states that she feels fatigued all the time and does not get good sleep.  She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours.  Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom.  She thinks she may snore, but she is not sure.  She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY:  ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS:  ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination:  Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds.  Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION:  ,As before is nonfocal.  Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance.  The nature of this lesion is unclear.  Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1.  Left facial twitching-appears to be improving.  Most likely, this is a peripheral nerve injury related to her abscess as previously described.  In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2.  Posterior pressure like headache, also appears to be improving.  The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3.  Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep.  There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study.  For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep.  She is on vacation next week and is going to try to see if this will help.  We also discussed as before weight loss and exercise, which could be helpful.,4.  Right clivus and petrous lesion of unknown etiology.  We will repeat the MRI at four months to see for interval change.,5.  The patient voiced understanding of these plans and will be following up with me in five months.",Consult - Facial Twitching,Neurology,"neurology, grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching,"
Complete heart block with pacemaker malfunction and  a history of Shone complex.,"HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.",Shone complex,Cardiovascular / Pulmonary,
"A 5-month-old infant with cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.","CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days.  Mom states she had no fever.  Her appetite was good but she was spitting up a lot.  She had no difficulty breathing and her cough was described as dry and hacky.  At that time, physical exam showed a right TM, which was red.  Left TM was okay.  She was fairly congested but looked happy and playful.  She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear.  Mom returned to clinic again today because she got much worse overnight.  She was having difficulty breathing.  She was much more congested and her appetite had decreased significantly today.  She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS:  ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY:  ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces.  No complications.  Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY:  ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her respiratory rate was approximately 60 to 65.,GENERAL:  She was very congested and she looked miserable.  She had no retractions at this time.,HEENT:  Her right TM was still red and irritated with no light reflex.  Her nasal discharge was thick and whitish yellow.  Her throat was clear.  Her extraocular muscles were intact.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR EXAM:  She was tachycardic without murmur.,LUNGS:  Revealed diffuse expiratory wheezing.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.,LABORATORY DATA:  ,Her chem panel was normal.  RSV screen is positive.  Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN:  ,RSV bronchiolitis with otitis media.  Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.",Congestion & Cough - 5-month-Old,Pediatrics - Neonatal,
2-D M-Mode. Doppler.,"2-D M-MODE: , ,1.  Left atrial enlargement with left atrial diameter of 4.7 cm.,2.  Normal size right and left ventricle.,3.  Normal LV systolic function with left ventricular ejection fraction of 51%.,4.  Normal LV diastolic function.,5.  No pericardial effusion.,6.  Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7.  PA systolic pressure is 36 mmHg.,DOPPLER: , ,1.  Mild mitral and tricuspid regurgitation.,2.  Trace aortic and pulmonary regurgitation.",2-D Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv"
13 years old complaining about severe ear pain - Chronic otitis media.,"PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets ""fast food"" once or twice a week according to his Mom.  He says he eats ""a lot"" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of ""heartburn"" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.",Ear pain - Pediatric Consult,Pediatrics - Neonatal,
"Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.","PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.",Pigtail Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,"
Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.,"REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.",Lumbar Puncture,Neurosurgery,
"Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.","PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.",Selective Coronary Angiography & Angioplasty,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,"
"History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.","CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and ""crack chest pain"" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.2",Small Bowel Obstruction,Gastroenterology,
Stress test with Bruce protocol due to chest pain.,"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.,",Stress Test Bruce Protocol,Radiology,
A sample note on Conjunctivitis (Pink Eye).,"CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid.  It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1.  Red, irritated eye.,2.  Some burning and/or scratchy feeling.,3.  There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye.  It may or may not need medication for treatment.  If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1.  Wash hands thoroughly before you use the medicine in your eyes.  After using the medicine in your eyes.  Every time you touch your eyes or face.,2.  Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3.  Do not share make-up.  If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4.  Do not touch the infected eye because the infection will spread to the good eye.  IMPORTANT!!!,5.  Pink Eye Spreads Very Easily!",Conjunctivitis,Ophthalmology,"ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye"
"Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","Heart Catheterization, Ventriculography, & Angiography - 11",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography"
The patient was admitted after undergoing a drawn out process with a small bowel obstruction.,"DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.",Discharge Summary - Respiratory Failure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge,"
A sample note on Angina.,"ANGINA, is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women.  It is usually located right under the breast bone.  Physical and emotional stress, as well as eating heavy meals, can bring it on.  In a healthy person, these stresses are easily handled.  In a person with an underlying heart condition like coronary artery disease, heart valve problem, arrhythmias or high blood pressure, the heart doesn't get enough blood (i.e. not enough oxygen to the heart muscles).  Other causes could be due to a hyperactive thyroid disorder or anemia.  People more likely to have angina may also have diabetes mellitus, be overweight, smoke, have a poor diet with lots of salt and fat, fail to exercise, have a stressful workload or have a family history of coronary artery disease.,SIGNS AND SYMPTOMS:,*  Pain in chest described as tightness, heavy pressure, aching or squeezing.,*  The pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.,*  Possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.,*  Occasionally a sudden difficulty in breathing occurs.,*  Pain may be located between the shoulder blades.,TREATMENT:,*  Nitroglycerin relieves the immediate symptoms of angina in seconds.  Carry it with you at all times.,*  Other medications may be prescribed for the underlying heart problems.  It is important to take them as prescribed by your doctor.,*  Surgery may be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.,*  Correct the contributing factors you have control over.  Lose weight, don't smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina.  Such stressors include anger, overworking, going between extremes in hot and cold, sudden physical exertion and high altitudes (pressurized airplanes aren't a risk).  Practice relaxation techniques.,*  Exercise! Discuss first what you are able to do with your doctor and then go do it.,*  Even with treatment, angina may result in a heart attack, congestive heart failure or a fatal abnormal heartbeat.  Treatment decreases the odds that these will occur.,*  Let your doctor know if your angina doesn't go away after 10 minutes, even when you have taken a nitroglycerin tablet.  Call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps.  If your pain changes or feels different, call your doctor or call 911 if the pain is severe.",Angina,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lack of oxygen, heart valve, arrhythmias, blood pressure, heart, tightness, nitroglycerin, coronary artery disease, oxygen, angina, coronary, chest,"
"Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.","PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.",Bunionectomy & Akin Osteotomy,Orthopedic,"orthopedic, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot"
"Abnormal cardiac enzyme profile.  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.","REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.",Elevated Cardiac Enzymes,Cardiovascular / Pulmonary,
Small office note on premature retina and vitreous.,"OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,",Premature retina and vitreous,Ophthalmology,"ophthalmology, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,"
Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.,"XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  He is requesting to come off the Dilantin at this point.  Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  His physical exam, neurologically, is normal at this time.  His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time.  I understand this will probably entail repeating his EEG and so please coordinate this through Health Center.  I await your response and whether we should continue this medication.  If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling.",Suspected Seizure Activity,Neurology,"neurology, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Patient has trouble with walking and balance, with bladder control, and with thinking and memory.","REASON FOR VISIT:  ,The patient is a 76-year-old man referred for neurological consultation by Dr. X.  The patient is companied to clinic today by his wife and daughter.  He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory.  When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years.  At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  As time progressed, he developed more and more difficulty.  He started to shuffle.  He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006.  At this point, he frequently if not always has trouble getting in or out of the seat.  He frequently tends to lean backwards or sideways when sitting.  He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  He has not fallen in the last month.  He did fall earlier, but there seemed to be fewer opportunities for him to fall.  His family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  He has no stairs in his home, however, his family indicates that he would not be able to take stairs.  His handwriting has become smaller and shakier.,In regard to the bladder, he states, ""I wet the bed.""  In talking with his family, it seems as if he has no warning that he needs to empty his bladder.  He was diagnosed with a small bladder tumor in 2005.  This was treated by Dr. Y.  Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  The patient has worn a pad or undergarment for at least one to one and a half years.  His wife states that they go through two or three of them per day.  He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  Now he seems less spontaneous and his family states he seems to have trouble expressing himself.  His wife took over his medications about two years ago.  She stopped his driving about three years ago.  She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  Apparently, he did not object.  At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  He is a retired office machine repairman.  He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease.  He has been treated for the bladder.  He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  The bladder tumor was discovered in 2005 and was treated noninvasively.  He has lost weight from about 200 pounds to 180 pounds over the last two or three years.  He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped.  He used to drink a significant amount of alcohol.  This was problematic enough that his wife was concerned.  She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY:  ,He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches.,FAMILY HISTORY:  ,His grandfather had arthritis.  His father had Parkinson's disease.  His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  He is well developed, well nourished, and kempt.,Vital Signs:  His weight is 180 pounds.,Head:  The head is normocephalic and atraumatic.  The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine:  The spine is straight and not tender.  I can easily palpate the spinous processes.  There is no scoliosis.,Skin:  No neurocutaneous stigmata.,Cardiovascular Examination:  No carotid or vertebral bruits.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 17/30.  He did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  There was a tendency for perseveration during the evaluation.  He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam:  No evidence of papilledema.  The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam:  Normal bulk and strength, but the tone is marked by significant paratonia.  There is no atrophy, fasciculations, or drift.  There is tremulousness of the outstretched hands.,Sensory Exam:  Is difficult to interpret.  Either he does not understand the test or he is mostly guessing.,Cerebellar Exam:  Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  There is no dysarthria.,Reflexes:  Trace in the arms, 2+ at the knees, and 0 at the ankles.  It is not certain whether there is a Babinski sign or simply withdrawal.,Gait:  Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology.  It shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  The 3rd ventricle contour is flat.  The span is enlarged at 12 mm.  The sylvian aqueduct is patent.  There is a pulsation artifact.  The corpus callosum is effaced.  There are extensive T2 signal abnormalities that are confluent in the corona radiata.  There are also scattered T2 abnormalities in the basal ganglia.  There is a suggestion of hippocampal atrophy.  There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1.  Possible idiopathic normal pressure hydrocephalus (331.5).,2.  Probable cerebral small-vessel disease (290.40 & 438).,3.  Gait impairment (781.2).,4.  Urinary urgency and incontinence (788.33).,5.  Dementia.,6.  Hypertension.,7.  Hypercholesterolemia.",Neurologic Consultation - 3,Neurology,
"A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.","HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.",Complex Cyanotic Congenital Heart Disease,Cardiovascular / Pulmonary,
"Blood in toilet.  Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.","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.",Blood In Toilet,Gastroenterology,
Open septorhinoplasty with placement of bilateral spreader grafts.  Bilateral lateral osteotomies.,"PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1.  Open septorhinoplasty with placement of bilateral spreader grafts.,2.  Placement of a radiated rib tip graft.,3.  Placement of a morcellized autogenous cartilage dorsal onlay graft.,4.  Placement of endogen, radiated collagen dorsal onlay graft.,5.  Placement of autogenous cartilage columellar strut graft.,6.  Bilateral lateral osteotomies.,7.  Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8.  Fracture of right upper lateral cartilage.,ANESTHESIA:  ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,100 mL.,URINE OUTPUT:,  Not recorded.,SPECIMENS:,  None.,DRAINS: , None.,FINDINGS:  ,1.  The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2.  The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3.  The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity.  The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity.  He was found to have a C-shaped deformity to the left as well as some tip ptosis.  The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table.  The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty.  The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees.  Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally.  The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally.  Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision.  This incision was made using a #15 blade.  A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura.  However, there was a dissection injury to the left medial crura.  Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage.  Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion.  Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions.  There was also an obvious fracture of the right upper lateral cartilage.  There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump.  The skin was contributing to the patient's cosmetic deformity.  In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage.  This mucocele was attempted to be dissected free, most of which was removed via dissection.  We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome.  The dorsal hump was taken down and passed off the table.  Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage.  This was passed off to use later for possible onlay grafts.  There was now a marked open roof deformity of the cartilage and bony sprue.  A septoplasty was then performed throughout and a Kelly incision on the right side.  Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side.  A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut.  This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities.  The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally.  Once these were placed, we then proceeded to work on the bony open roof.  Lateral osteotomies were made with 2-mm osteotomes bilaterally.  The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum.  We then proceeded to the tip.  A cartilaginous strut was then fashioned from the cartilaginous septum.  It was approximately 15 mm long.  This was placed, and a pocket was just formed between the medial crura.  This pocket was taken down to the nasal spine, and then, the strut graft was placed.  The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition.  The intradermal sutures were then placed to help to align the nasal tip.  The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing.  Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot.  The patient had good tip support after this maneuver.  We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome.  This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen.  The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft.  Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages.  Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts.  This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness.  There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point.  The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion.  The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture.  Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture.  The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct.  A Denver external splint was then applied.  The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition.",Septorhinoplasty,ENT - Otolaryngology,
Bronchoscopy for hypoxia and increasing pulmonary secretions,"PREOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,POSTOPERATIVE DIAGNOSIS: , Hypoxia and increasing pulmonary secretions.,OPERATION: , Bronchoscopy.,ANESTHESIA: , Moderate bedside sedation.,COMPLICATIONS:,  None.,FINDINGS:,  Abundant amount of clear thick secretions throughout the main airways.,INDICATIONS:,  The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion.  This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube.  The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray.  Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,OPERATION:,  The patient was given additional fentanyl, Versed as well as paralytics for the procedure.  Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina.  There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus.  Extensive secretions extended down into the secondary airways.  This was lavaged with saline and suctioned dry.  There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum.  The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned.  The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator.  Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2.  The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.",Bronchoscopy - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,"
Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.  Closed displaced angulated fracture of the right distal radius.,"PREOPERATIVE DIAGNOSIS:  ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist.  He was placed into a well-molded splint after reduction was performed in the emergency department.  Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted.  All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure.  The right upper extremity was prepped and draped in a sterile fashion.  A 5-cm incision was made over the flexor carpi radialis of the right wrist.  The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus.  Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue.  Next, a reduction was performed placing the distal fragment into appropriate alignment.  This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position.  An Acumed Accu-lock plate was placed along the volar aspect of the distal radius.  This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment.  A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position.  Two distal locking screws were placed along the plate itself.  The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular.  Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate.  All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture.  AP and lateral views were taken of these screw placements again.  None of these screws were into the joint and all had appropriate length into the dorsal cortex.  Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase.  AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws.  Bicortical purchase was appreciated and no screws were placed into the joint.  The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint.  The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.",ORIF Wrist - Acumed Locking Plate,Orthopedic,"orthopedic, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist"
Echocardiogram with color flow and conventional Doppler interrogation.,"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.",Echocardiogram,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation,"
"Ankle sprain, left ankle.  The patient tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.","DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08.  The patient states that she tripped over her dog toy and fell with her left foot inverted.  The patient states that she received a series of x-rays and MRIs that were unremarkable.  After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle.  She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer.  The cervical cancer was diagnosed as 15 years old.  The patient states that her cancer is ""dormant."",MEDICATIONS:,1.  Hydrochlorothiazide.,2.  Lisinopril.,3.  Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale.  The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain.  The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional.  The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities.  The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time.  The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY:  ,The patient lives in a private home with children and her father.  The patient states that she does have stairs to negotiate without the use of a railing.  She states that she is able to manage the stairs, however, is very slow with her movement.  The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot.  Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention.  When compared to right ankle edema, it is approximately equal.  There is no evidence of discoloration or temperature.  The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows:  Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees.  Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful.  The patient was tearful during this activity.  Eversion is 3 degrees and inversion is 25 degrees.  The patient states this movement was difficult, but not painful.  Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:,  A 6-minute walk test.  The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT:  ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to complete work task and functional activities in the home.,5.  Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1.  The patient will demonstrate independence with home exercise program.,2.  The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3.  The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4.  The patient will demonstrate 3/5 strength of the left ankle.,5.  The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1.  The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2.  The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:,  Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:",Physical Therapy - Ankle Sprain,Orthopedic,
"Right total knee arthroplasty - Osteoarthritis, right knee.","PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.",Total Knee Arthroplasty - Right,Orthopedic,"orthopedic, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia,"
Psychiatric evaluation for major depression without psychotic features.,"IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:,  Depression.,HISTORY OF PRESENT ILLNESS:,  The patient's depression began in her teenage years.  Sleep has been poor, for multiple reasons.  She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  The patient tends to feel irritable, and has crying spells.  She sometimes has problems with motivation.  She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change.  Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine.  She does not have suicidal thoughts.  ,The patient also has what she describes as going into a ""panic mode.""  During these times, she feels as if her whole body is going to explode.  She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  These spells may last a couple of hours, but once lasted for about two day.  She does not get chest pain.  These attacks tend to be precipitated by bills that cannot be paid, or being on a ""time crunch."" ,PSYCHIATRIC HISTORY:,  The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking.  Although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times.  At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  She has never been hospitalized for psychiatric purposes.  She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine:  The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco:  She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day.  She is still committed to quitting.,Alcohol: Denied.,Illicit drugs:  Denied.  In her earlier years, someone once put some unknown drug in her milk, and she ""came to"" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional:  See History of Present Illness. No recent fever or sweats.",Psychiatric Evaluation - 2,Psychiatry / Psychology,
Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.,"CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005.  Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain.  He states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  He rated his pain today as 6/10, describing it is shooting, sharp and aching.  It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  It is constant but variable in degree.  It continues to affect activities and sleep at night as well as mood at times.  He is currently not satisfied completely with his level of pain relief.,MEDICATIONS: , Kadian 30 mg b.i.d., Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n.,ALLERGIES:,  No known drug allergies.,REVIEW OF SYSTEMS:,  Complete multisystem review was noted and signed in the chart.,SOCIAL HISTORY:,  Unchanged from prior visit.,PHYSICAL EXAMINATION: , Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  He is a well-developed obese male in no acute distress.  He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  He ambulates with normal gait and has normal station.  He is able to heel and toe walk.  He denies any sensory changes.,ASSESSMENT & PLAN: , This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  We discussed treatment options at length and he is willing to undergo a trial of Lyrica.,He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.",Orthopedic Consult - 4,Orthopedic,"orthopedic, radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement"
Recurrent anterior dislocating left shoulder.  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,"PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:,  Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:,  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area.  The patient was positioned in the modified beachchair position utilizing the Mayfield headrest.  The left shoulder was propped posteriorly with a rolled towel.  His head was secured to the Mayfield headrest.  The left shoulder and upper extremity were then prepped and draped in the usual manner.  A posterior lateral port was made for _____ the arthroscopic cannula.  The scope was introduced into the glenohumeral joint.  There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock.  The labrum was adherent to the underlying capsule.  The margin of the glenoid was frayed in this area.  The biceps tendon was noted to be intact.  The articular surface of the glenoid was fairly well preserved.  The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head.  The rotator cuff was visualized and noted to be intact.  The axillary pouch was visualized and it was free of injury.  There were some cartilaginous fragments within the axillary pouch.  Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum.  Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position.  A second tack was then placed at about the 8 o'clock position.  The labrum was then probed and was noted to be stable.  With some general ranging of the shoulder, the tissue was pulled out from the tacks.  An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position.  Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area.  At this point, it was deemed that an open Bankart arthroplasty was necessary.  The arthroscopic instruments were removed.  An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold.  The skin incision was taken down through the skin.  Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis.  The deltopectoral fascia was identified.  It was split at the deltopectoral interval and the deltoid was reflected laterally.  The subdeltoid bursa was then removed with rongeurs.  The conjoint tendon was identified.  The deltoid and conjoint tendons were then retracted with a self-retaining retractor.  The subscapularis tendon was identified.  It was separated about a centimeter from its insertion, leaving the tissue to do sew later.  The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially.  This allowed for visualization of the capsule.  The capsule was split near the humeral head insertion leaving a tag for repair.  It was then split longitudinally towards the glenoid at approximately 9 o'clock position.  This provided visualization of the glenohumeral joint.  The friable labral and capsular tissue was identified.  The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock.  The sutures were passed through the labral capsular tissue and tied securely.  At this point, the anterior glenoid rim had been recreated.  The joint was then copiously irrigated with gentamicin solution and suctioned dry.  The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture.  This later was then copiously irrigated with gentamicin solution and suctioned dry.  Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture.  This later was then copiously irrigated as well and suctioned dry.  The deltoid fascia was approximated with running #2-0 Vicryl suture.  Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips.  0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia.  The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied.  The patient was then transferred to the recovery room in apparent satisfactory condition.",Arthroscopic Debridement - Shoulder,Orthopedic,"orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis"
"This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.","PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of",YAG Laser Capsulotomy - 1,Ophthalmology,"ophthalmology, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular,"
Right hip osteoarthritis.  Total hip replacement on the right side.,"PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1.  Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2.  Trabecular metal modular acetabular system 48 mm in diameter.,3.  Femoral head 32 mm diameter +0 mm neck length.,4.  Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:,  The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up.  After review of allergies, antibiotics were administered and time out was performed.  The right lower extremity was prepped and draped in a sterile fashion.  A 15 cm to 25 cm in length, an incision was made over the greater trochanter.  This was angled posteriorly.  Access to the tensor fascia lata was performed.  This was incised with the use of scissors.  Gluteus maximus was separated.  The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie.  Hemostasis was achieved.  The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb.  It was detached from the piriformis fossa and tagged with 2-0 Vicryl.  Access to the capsule was performed.  The capsule was excised from the posterior and superior aspects.  It was released also in the front with the use of a Mayo scissors.  The hip was then dislocated.  With the use of an oscillating saw, the femoral neck cut was performed.  The acetabulum was then visualized and debrided from soft tissues and osteophytes.  Reaming was initiated and completed for a 48 mm diameter cap without complications.  The trial component was put in place and was found to be stable in an anatomic position.  The actual component was then impacted in the acetabulum.  A 10-degree lip polyethylene was also placed in the acetabular cap.  Our attention was then focused to the femur.  With the use of a cookie cutter, the femoral canal was accessed.  The broaching process was initiated for No.4 trial component.  Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation.  In addition, in full extension and external rotation, there was no dislocation.  The actual component was inserted in place and hemostasis was achieved again.  The wound was irrigated with normal saline.  The wound was then closed in layers.  Before performing that the medium-sized Hemovac drain was placed in the wound.  The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl.  Staples were used for the skin.  The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition.  She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions.  We will start the DVT prophylaxis after the removal of the epidural catheter.",Total Hip Replacement,Orthopedic,"orthopedic, total hip replacement, epidural catheter, tensor fascia lata, hemostasis was achieved, medium sized hemovac, tensor fascia, fascia lata, trial component, medium sized, sized hemovac, total hip, hip replacement, hip osteoarthritis, piriformis fossa, total, hip, acetabular, extremity, tensor, fascia, hemostasis, acetabulum, dislocation, hemovac, replacement, osteoarthritis, femoral, piriformis, fossa, components, anesthesia,"
"Esophagoscopy with removal of foreign body.   Esophageal foreign body, no associated comorbidities are noted.","PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.",Esophagoscopy & Foreign Body Removal - 1,Gastroenterology,"gastroenterology, esophagus, foreign body, esophagoscopy, esophageal,"
Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS:  ,None.,COMPLICATIONS:,  None.,ANESTHESIA:,  General.,SKIN PREPARATION:  ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size.  Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left.  The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner.  The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter.  The ventricular catheter was then disconnected from the reservoir and endoscopically explored.  We saw it was blocked up proximally.  The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter.  The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle.  It irrigated out well.  There was minimal amount of bleeding, but not significant.  The distal catheter system was tested.  There was good distal run off.  Therefore, a linear skin incision was made in the retroauricular area.  Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve.  All connections were secured with 2-0 Ethibond sutures.  Careful attention was made to make sure that the ProGAV was in the right orientation.  The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.  He was awakened, extubated and taken to recovery room in satisfactory condition.",Shunt Revision - 2,Neurosurgery,"neurosurgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,"
Patient with right ankle pain.,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",MRI Ankle - 2,Orthopedic,
Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.,"CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,",GI Consultation - 4,Gastroenterology,
Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,"PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",Fistulogram & Angioplasty,Cardiovascular / Pulmonary,
"Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.","REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.",Colon Cancer Consult,Gastroenterology,
"The patient with gradual onset of a headache problem, located behind both eyes.","CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:",Migraine without Aura - Consult,Neurology,
"Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.","PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.",ORIF Mandibular Fracture & Dental Implant Removal,Orthopedic,"orthopedic, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,"
"Chest x-ray on admission, no acute finding, no interval change.  CT angiography, negative for pulmonary arterial embolism.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.","PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.",Discharge Summary - COPD,Cardiovascular / Pulmonary,
"White male with onset of chest pain, with history of on and off chest discomfort over the past several days.","INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.",Cardiac Catheterization - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,"
Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,"INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.",Cardiac Consultation - 6,Cardiovascular / Pulmonary,
Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,"PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.",Fiberoptic Bronchoscopy with Lavage,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory,"
"Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.","DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,",Bronchiolitis - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs,"
MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.,"CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician",MRI Brain and C-T Spine,Neurology,
"Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.","PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",Endoscopic Sinus Surgery,ENT - Otolaryngology,
"Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.","DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.",Phacoemulsification & Cataract Extraction,Ophthalmology,"ophthalmology, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE"
The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 4,Neurology,
"The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.","REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",Neuroblastoma - Consult,Hematology - Oncology,
"Acute appendicitis, gangrenous.  Appendectomy.","PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions.  After having obtained an informed consent, he was placed in the operating room and under anesthesia.  Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  Antibiotics had been given prior to incision.  A McBurney incision was performed and it carried out through the peritoneal cavity.  Immediately there was  purulent material seen in the area.  Samples were taken for culture and sensitivity of aerobic and anaerobic sets.  The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  There was quite a bit of local peritonitis.  The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch.  The area was abundantly irrigated with normal saline and also the pelvis.  The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,",Appendectomy - 1,Gastroenterology,"gastroenterology, mcburney incision, abdominal, small bowel, acute appendicitis, appendectomy, gangrenous, appendix,"
Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.,"EXAM: , Modified barium swallow.,SYMPTOM:,  Dysphagia with possible aspiration.,FINDINGS:,  A cookie deglutition study was performed.  The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of penetration with thin liquids.  This is not evident with thick liquids, semisolids or solids.,There is weakness in the oral phase of deglutition.  Subglottic region appears normal.  There is no evidence of aspiration demonstrated.,IMPRESSION: , Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.",Deglutition Study - Modified Barium swallow,Gastroenterology,"gastroenterology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition,"
Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.,"REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.",Thyroid Mass Consult,Hematology - Oncology,
"Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.","PROCEDURE:,  Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male.  He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease.  Previous ST elevation MI.,REVIEW OF SYSTEMS.,  The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1.  Visipaque 361 mL total dose.,2.  Clopidogrel bisulphate (Plavix) 225 mg PO,3.  Promethazine (Phenergan) 12.5 mg total dose.,4.  Abciximab (Reopro) 10 mg IV bolus,5.  Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6.  Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1.  Balloon catheter utilized:  Manufacturer:  Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2.  Cordis Vista Brite Tip 6Fr JR 4.0,3.  ACS/Guidant Sport .014"" (190cm) Wire,4.  Stent utilized:  Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:,  The overall left ventricular systolic function is mildly reduced.  Left ventricular ejection fraction is 40% by left ventriculogram.  Mild hypokinesis of the anterior wall of the left ventricle.  There was no transaortic gradient.  Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY:  ,  There were no obstructing lesions in the left main coronary artery.  Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery.  A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  Post-procedure stenosis was 0%.  There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:,  The right coronary artery is dominant to the posterior circulation.  There were no obstructing lesions in the right coronary artery.  Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1.  Severe two-vessel coronary artery disease.,2.  Severe left anterior descending coronary artery disease.  There was a 95% mid left anterior descending artery stenosis.  The lesion was successfully stented.,3.  Moderate left circumflex artery disease.  There was a 50% left circumflex artery stenosis.  Intervention not warranted.,4.  The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1.  Clopidogrel (Plavix) 75 mg PO daily for 1 year.",Cardiac Cath & Coronary Angiography,Cardiovascular / Pulmonary,
"Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.","PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.",Bunionectomy & Metatarsal Osteotomy,Orthopedic,"orthopedic, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,"
"Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.","REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times ""I do not feel well"" and looked ""glazed.""  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he ""felt fine the whole time.""  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related ""memory lapses"" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed ""mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes ""every year of school"" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 1,Psychiatry / Psychology,
"Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.  Tonsillitis with hypertrophy.  Edema to the uvula and soft palate.","PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.",Nasal Septoplasty & Tonsillectomy,ENT - Otolaryngology,"ent - otolaryngology, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,"
CCTA with cardiac function and calcium scoring.,"HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS:  ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation.  Patient received oral Metoprolol 100 milligrams.  100 ml Ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits.  Left ventricular ejection fraction calculated to be 82%.  End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins.  There is codominance between the right coronary artery and the circumflex artery.  There is mild to moderate stenosis of the proximal LAD with mixed plaque.  Mild stenosis mid LAD with mixed plaque.  No stenosis.  Distal LAD with the distal vessel becoming diminutive in size.  Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  Once again the distal vessel becomes diminutive in size.  Circumflex shows mild stenosis due to focal calcified plaque proximally.  No stenosis is seen involving the mid or distal circumflex.  The distal circumflex also becomes diminutive in size.  The left main shows small amount of focal calcified plaque without stenosis.  Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1.  Atherosclerotic coronary artery disease with values as above.  There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2.  Consider cardiology consult and further evaluation if clinically indicated.,3.  Full report was sent to the PACS.  Report will be mailed to Dr. ABC.",Coronary CT Angiography (CCTA) - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis,"
"Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement.  Right renal mass and ureteropelvic junction obstruction and hematuria.","PREOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Hematuria.,POSTOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right ureteral pyeloscopy.,4.  Right renal biopsy.,5.  Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:,  The patient is a 74-year-old male who was initially seen in the office with hematuria.  He was then brought to the hospital for other medical problems and found to still have hematuria.  He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position.  He was given IV sedation and placed in dorsal lithotomy position.  He was then prepped and draped in the standard fashion.  A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  There were no masses or any other abnormalities noted other than the tuberculation.  Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  A retrograde pyelogram was performed.  Upon visualization, there was no visualization of the upper collecting system on the right side.  At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  The bladder was drained and the cystoscope was removed.  The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities.  The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance.  The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction.  The wire was then again passed through the flexible scope and the flexible scope was removed.  A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation.  The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  Once this was done, the wire was left in place and the ureteroscope was removed.  The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  The stent was noted to be clear within the right renal pelvis as well as in the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  He will be transferred to the recovery room and back to his room.  It has been discussed with his primary physician that the patient will likely need a nephrectomy.  He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.",Cystourethroscopy & Retrograde Pyelogram - 1,Nephrology,"nephrology, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder"
"Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.","PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.",Radiofrequency Ablation,Orthopedic,"orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,"
Extensive stage small cell lung cancer.  Chemotherapy with carboplatin and etoposide.  Left scapular pain status post CT scan of the thorax.,"CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Lung Cancer Followup,Hematology - Oncology,"hematology - oncology, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer,"
"Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.","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.",Stress Test Dobutamine Myoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion,"
Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation.,"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",Psychosocial Eval - Donor - 1,Nephrology,
This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",Ultrasound OB - 5,Obstetrics / Gynecology,
Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps.,"Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.",Delivery Note - 2,Obstetrics / Gynecology,"obstetrics / gynecology, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.","2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.",2-D Doppler,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,"
MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",MRI T-L Spine - Schistosomiasis,Radiology,
Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.,"PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.",Laparoscopic Appendectomy - 3,Gastroenterology,"gastroenterology, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix,"
"Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.","PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.","D&C, Laparoscopy, & Salpingectomy",Obstetrics / Gynecology,"obstetrics / gynecology, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,"
Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection.,"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.",Mitral Valve Repair & Annuloplasty,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral,"
"Ethmoidectomy, antrostomy with polyp removal, turbinectomy, and septoplasty.","PREOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1.  Left chronic anterior and posterior ethmoiditis.,2.  Left chronic maxillary sinusitis with polyps.,3.  Left inferior turbinate hypertrophy.,4.  Right anterior and posterior chronic ethmoiditis.,5.  Right chronic maxillary sinusitis with polyps.,6.  Right chronic inferior turbinate hypertrophic.,7.  Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis.  She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum.  Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision.  A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator.  The bony deflection was removed using Jansen-Middleton forceps.  The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest.  The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side.  Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps.  Approximately 10 cc total was used.  The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better.  The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps.  Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site.  The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection.  Bright mucosal disease and small polypoid accumulations were noted through the sinuses also.  The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy.  The mucosal polypoid accumulations were cleared using the Richards essential shaver.  The turbinate was partially resected from mucosally but with good shape to it.  It was not desirable to remove it in its entirety.  Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used.  The polyps were removed.  The Richards essential shaver was used to allow better exposure of the uncinate process.  The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also.  The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection.  The inferior turbinates showed mucosal disease, polypoid accumulations, and changes.  These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus.  A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions.  The patient tolerated the procedure well and returned to the recovery room in stable condition.",Endoscopic Sinus Surgery,ENT - Otolaryngology,
"Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.","PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.",Pectoralis Tendon Repair,Orthopedic,"orthopedic, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures,"
Common description of colonoscopy,"A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve.  This was done without difficulty and the bowel preparation was good.  The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal.  The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.",Colonoscopy Template - 4,Gastroenterology,"gastroenterology, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.","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.",Thoracoscopy/Thoracotomy,ENT - Otolaryngology,"ent - otolaryngology, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,"
"Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.","PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.",Diverticulectomy & Laparotomy,Gastroenterology,
Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.,"REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:,  Historical information was obtained from a review of available medical records and clinical interview with Ms. A.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  Neurological evaluation with Dr. X confirmed left hemiparesis.  Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness.  These symptoms were thought to be due to a right middle cerebral artery stroke.  She was transferred to the ICU for monitoring.  Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA.  On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA.  At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane.  She was discharged home with recommendations for outpatient physical therapy.  She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  Brain CT on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup.  Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change.  MRI could not be completed due to the patient's weight.  She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at.  Note also that she had some difficulty explaining exactly what her job involved.  She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY:  ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night.  She reported that since her appointment with Dr. X, she has been using it ""every other night.""  When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  She receives approximately two to five hours of sleep per night.  Other current untreated risk factors include obesity and hypercholesterolemia.  Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:,  Ms. A denied drinking alcohol or using illicit drugs.  She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history.  She reported that her mother died three to four years ago from lung cancer.  Her father has gout and blood clots.  Siblings have reportedly been treated for asthma and GI tumors.  She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree.  She reported that she primarily obtained B's and C's in school.  She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing.  As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  She is now living on her own.  She has never driven.  She reported that she continues to perform ADLs independently such as cooking and cleaning.  She lost her husband in 2005 and has three adult daughters.  She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  She also reported number of other family members who had recently passed away.  She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment.  She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  She reported that this only ""comes and goes."",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II),  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation,Neurology,
"Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.","HISTORY:  ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain.  This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue.  This numbness has been present for approximately two months.  It seems to be there ""all the time.""  He was seen by his dentist and after dental evaluation was noted to be ""okay.""  He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time.  He has been taking cough drops and trying to increase his fluids.  He has recently stopped tobacco.  He has been chewing tobacco for about 30 years.  Again, there is concern regarding the numbness he has been having.  He has had a loss of sensation of taste as well.  Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip.  He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity.  He has had no trauma to the face.  He does note a history of headaches.  These are occasional and he gets these within the neck area when they do flare up.  The headaches are noted to be less than one or two times per month.  The patient does note he has a history of anxiety disorder as well.  He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time.  He denies any fever or chills.  He is not having any dental pain with biting down.  He has had no jaw popping and no trismus noted.  The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:,  Tylenol.  He is on Nicorette gum.,ALLERGIES:  ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY:  ,The patient is single, self-employed carpenter.  He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Both ears, external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  He does have moderate tympanosclerosis noted, no erythema.  Weber exam is midline.  Hearing is grossly intact and normal.,NASAL:  Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  He does have slightly decreased sensation to the left jaw.  He is able to feel pressure on touch.  This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed.  See separate operative report in chart.  This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION:  ,1.  Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2.  History of tobacco use.,3.  Hypogeusia with loss of taste.,4.  Headaches.,5.  Xerostomia.,RECOMMENDATIONS:,  I have ordered a CT of the head.  This includes sinuses and mandible.  This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had.  On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted.  I did recommend he increase his fluid intake.  He is to remain off the tobacco.  I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.",Consult - Jaw Pain,ENT - Otolaryngology,
"Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.","CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.",Elbow Pain - Consult,Orthopedic,
"Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.","HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",Cardiac Consult & Cardioversion,Cardiovascular / Pulmonary,
"Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.","EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.",Cardiac Catheterization,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,"
"Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.","PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.",Heart Catheterization & Ventriculogram,Cardiovascular / Pulmonary,
"Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy","HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.",Pulmonary Valve Stenosis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary,"
"Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.","PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",Anterior Cervical Discectomy & Interbody Fusion - 1,Neurosurgery,"neurosurgery, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical"
Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.,"PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.",Cecal Polyp Resection,Gastroenterology,"gastroenterology, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic"
Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization.,"PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.",Low-Transverse C-Section - 8,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord,"
"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.","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.",Transthoracic Echocardiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic"
Bilateral carotid ultrasound to evaluate pain.,"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.,",Ultrasound - Carotid - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,"
Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.,"PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury.  See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1.  Normal electrophysiologic studies.,2.  No inducible arrhythmia.,3.  Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1.  Comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies.  She received small amounts of intravenous fentanyl and Versed for conscious sedation.  Then 1% lidocaine local anesthesia was used.  Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle.  Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:,  Conduction intervals in sinus rhythm were normal.  Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms.  Sinus node recovery times were also normal at 1114 ms.  Corrected sinus node recovery time was normal at 330 ms.  One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms.  AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  RA-ERP was 250 ms.  With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  There was no inducible VT.  Longest run was 5 beats of polymorphic VT, which is a nonspecific finding.  From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes.  There were no ST segment changes.  HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies.  No evidence for sinus node dysfunction or atrioventricular block.  No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X.  She recently had an ambulatory EEG.  I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  Reveal event monitor was considered, but not placed since she has only had one single episode.",IV Procainamide Infusion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,"
"Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.","PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.",Tonsillectomy & Adenoidectomy - 1,ENT - Otolaryngology,"ent - otolaryngology, tongue, nasal passage, palate, mcivor mouth gag, gauze roll, nasopharynx, tonsillectomy, adenoidectomy,"
Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.,"CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:",Iron deficiency anemia,Hematology - Oncology,"hematology - oncology, trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco,"
This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,",Ultrasound OB - 5,Radiology,
"Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel.","PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy.,2.  Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3.  No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1.  Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2.  Total laminectomy C3, C4, C5, and C6.,3.  Excision of scar tissue.,4.  Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:,  1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:,  Less than 250 cc.,INDICATIONS FOR THE OPERATION:  ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  Last surgery consisted of four-level decompression on 08/28/06.  The patient continued to complain of posterior neck pain radiating to both trapezius.  Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis.  It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation.  Operation and expected outcome risks and benefits were discussed with him prior to the surgery.  Risks include but not exclusive of bleeding and infection.  Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  This too may require return to the operating room for evacuation of said pseudomeningocele and repair.  The patient understood the risk of the surgery.  I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring.  The SSEPs were normal, and the EMGs were silent during the entire case.  After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support.  Shave was then carried out over the occipital and suboccipital region.  All pressure points were padded.  I proceeded to mark the hypertrophic scar for excision.  This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified.  There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina.  With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery.  There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel.  By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7.  There was significant epidural bleeding, which was carefully coagulated.  At two points, I had to pack this with small pieces of Gelfoam.  After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage.  Area was irrigated with saline and bacitracin and then lined with Tisseel.  The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  The patient was extubated and transferred to recovery.",Facetectomy & Foraminotomy,Neurosurgery,
Transesophageal echocardiogram and direct current cardioversion.,"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.",Transesophageal Echocardiogram,Radiology,
"An 18-year-old white female who presents for complete physical, Pap, and breast exam.","SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.",Complete Physical - Female,Obstetrics / Gynecology,
Consultation because of irregular periods and ovarian cyst.,"She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.",OB/GYN Consultation - 2,Obstetrics / Gynecology,"obstetrics / gynecology, irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods"
"The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.","REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.",Pericardial Effusion,Cardiovascular / Pulmonary,
"Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.","Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD",Gastroenterology - Letter,Gastroenterology,
Sports physical with normal growth and development.,"HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.",Sports Physical - 1,Pediatrics - Neonatal,
The patient was admitted after undergoing a drawn out process with a small bowel obstruction.,"DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.",Discharge Summary - Respiratory Failure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge,"
Twin pregnancy with threatened preterm labor.,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:",Ultrasound OB - 4,Obstetrics / Gynecology,
Health maintenance exam for 1-year-old female.,"CHIEF COMPLAINT:,  This 1-year-old female presents today for a health maintenance exam.  Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle.  She sleeps through the night.  She takes morning and afternoon naps.  Mother is concerned about child's red, matted eye and not walking completely alone yet.  Immunizations need to be updated at today's visit.,DEVELOPMENTAL MILESTONES:,  1 year developmental milestones reached:  bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says ""mama"" and ""dada"" with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye.,ALLERGIES:,  No known medical allergies.,MEDICATIONS:,  None.,PMH: , Past medical history is unremarkable.,PSH: , No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather.,SOCIAL HISTORY:,  She lives at home with parents.  Patient admits being in daycare.,REVIEW OF SYSTEMS:,  No change since last visit,PHYSICAL EXAM:,  Temp:  97.6 Height:  0 ft.  31 in.  Weight:  28 lbs.  BMI:  20,Growth Chart Entry:  Weight:  28 lbs 0 ozs Height:  0 ft 31 in Head Circumference:  18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished.,Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic.,Eyes:  Fundoscopic exam reveals red reflex is present bilaterally.,Alignment is normal.,Sclera is white bilaterally.,Left inferior palpebral conjunctiva reveals conjunctivitis.,Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,ENT:  Pinna:  normal.,Otoscopic examination reveals no abnormalities of external auditory canals and tympanic membranes.,Inspection of nose reveals no abnormalities and nares that are normal.,Nasal mucosa moist, pink, and without mass or exudate with no abnormalities of the septum and turbinates noted.,Inspection of lips, gums, and palate reveals no abnormalities.,Examination of oropharynx reveals no abnormalities and tissues pink and moist.,Neck:  Neck exam reveals no masses.,Respiratory:  Assessment of respiratory effort reveals even and nonlabored respirations.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals rate is regular, rhythm is regular and no murmurs, gallop, rubs or clicks.  Femoral pulses are 2 /4, bilateral.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Genitourinary:  Examination of anus and perineum shows no abnormalities.,Musculoskeletal:  Inspection and palpation of bones, joints and muscles is unremarkable.,Muscle tone is normal.,Skin:  Skin is not pale, jaundice, or cyanotic.  Skin turgor, hydration, and texture is good.  Palpation of skin shows no abnormalities.,Neurologic/Psychiatric:  Moves all extremities.,TEST & X-RAY RESULTS:,  Hb:  12 g/dl.,IMPRESSION:,  Routine well child care.  Acute conjunctivitis.,PLAN:",1-year-old Exam - H&P,Pediatrics - Neonatal,
Right shoulder hemiarthroplasty.   Right shoulder rotator cuff tear.  Glenohumeral rotator cuff arthroscopy.  Degenerative joint disease.,"PREOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:,  None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY:  ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field.  Department of Anesthesia administered general anesthetic.  Once adequately sedated, the patient was placed in the beach chair position.  Care was ensured that she was well positioned, adequately secured and padded.  At this point, the right upper extremity was then prepped and draped in the usual sterile fashion.  A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue.  Any perforating bleeders were cauterized with Bovie to obtain hemostasis.  Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized.  At this point, the rotator cuff in the subacromial region was evaluated.  There was noted to be a large rotator cuff, which was irreparable.  There was eburnated bone on the greater tuberosity noted.  The articular surface could be visualized.  The biceps tendon was intact.  There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface.  The under surface of the acromion, it was felt there was mild ware on this as well.  At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture.  It was separated from the capsule to have a two layered repair at closure.  The capsule was also reflected posterior.  At this point, the glenoid surface could be easily visualized.  It was evaluated and had good cartilage contact and appeared to be intact.  The humeral head was evaluated.  There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head.  At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head.  The arm was adequately positioned.  An oscillating saw was used to make the head articular cut.  This was done at the margin of the articular surface with the anatomic neck.  This was taken down to appropriate level until this articular surface was adequately removed.  At this point, the intramedullary canal and cancellous bone could be easily visualized.  The opening hand reamers were then used and this was advanced to a size #10.  Under direct visualization, this was performed easily.  At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins.  This was then removed.  A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured.  It did not appear overstuffed with evidence of excellent range of motion and no impingement.  At this point, the trial component was removed.  Wound was copiously irrigated and suctioned dry.  Cement was then placed with a cement gun into the canal and taken up to the level of the cut.  The prosthesis was then inserted into place and held under direct visualization.  All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself.  This _______ cement was adequately hard at this point.  The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position.  The wound was again copiously irrigated and suctioned dry.  At this point, the capsule was then reattached to its insertion site in the anterior portion.  Once adequately sutured with #1-Vicryl, attention was directed to the subscapular.  The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity.  This was opened to allow some type of coverage points of the massive rotator cuff tear.  This was secured to the tissue and interosseous sutures with size #2 fiber wire.  After this was adequately secured, the wound was again copiously irrigated and suctioned dry.  The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl.  Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied.  The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.",Right Shoulder Hemiarthroplasty,Orthopedic,"orthopedic, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder,"
"Right and left heart catheterization, coronary angiography, left ventriculography.","PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,",Heart Catheterization,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions"
Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.,"PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.",Nasolabial Fold Elevation,ENT - Otolaryngology,
"Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.","PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.",Angiography & Catheterization,Cardiovascular / Pulmonary,
"Left heart catheterization, coronary angiography, and left ventriculogram.  No angiographic evidence of coronary artery disease.  Normal left ventricular systolic function.  Normal left ventricular end diastolic pressure.","PROCEDURES,1.  Left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculogram.,PREPROCEDURE DIAGNOSIS:,  Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,INDICATION:  ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:,  After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  He was prepped and draped in the usual sterile manner.  The right inguinal area was anesthetized with 2% Xylocaine.  A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique.  JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively.  Coronary angiographies were performed.  These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle.  Left ventriculography was performed.  The patient tolerated the procedure well.  At the end of the procedure, all catheters and sheaths were removed.  The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE:  ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL.  Ejection fraction was calculated to be 69%.  There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex.  The LAD is small in caliber.  In addition, there is a long bifurcating small-caliber diagonal branch noted.  LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch.  LCX and its branches are free of disease.,RCA:,  RCA is a dominant small-caliber vessel with long small-caliber PDA branch.  RCA and its branches are free of disease.,IMPRESSION,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.","Heart Catheterization, Ventriculography, & Angiography - 8",Cardiovascular / Pulmonary,
Psychosocial evaluation of kidney donor.  Questions - Answers,"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",Psychosocial Eval - Donor,Psychiatry / Psychology,
Right and Left carotid ultrasound,"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.",Ultrasound - Carotid - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,"
Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.,"POSTOPERATIVE DIAGNOSIS:  Fever.,PROCEDURES:  Bronchoalveolar lavage.,INDICATIONS FOR PROCEDURE:  The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008.  Greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,DESCRIPTION OF PROCEDURE:  The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure.  The correct patient and procedure was identified by time out by all members of the team.  The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction.  A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap.  A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology.  The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  A postoperative chest x-ray was obtained.",Bronchoalveolar lavage.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airwayNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Right knee total arthroplasty.  Degenerative osteoarthritis, right knee.","PREOPERATIVE DIAGNOSIS:,  Degenerative osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS: , Degenerative osteoarthritis, right knee.,PROCEDURE PERFORMED: ,Right knee total arthroplasty.,ANESTHESIA: , The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized.,TOTAL TOURNIQUET TIME: , Approximately 90 minutes.,SPECIFICATIONS: , The entire procedure is done in the inpatient operating suite in the Room #1 at ABCD General Hospital.  The following sizes of NexGen system were utilized:  E on right femur, cemented; 5 tibial stem tray with a 10 mm polyethylene insert, and a 32 mm patellar button.,HISTORY AND GROSS FINDINGS: , This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention.  She was completely refractory to conservative outpatient therapy.  She had undergone two knee arthroscopies in the years preceding this.  They were performed by myself.  She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live.  Medial compartment had minor changes present.  There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides.  There was no significant flexion contracture preoperatively.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table after receiving a subarachnoid block anesthetic by the Anesthesia Department.  Thigh tourniquet was placed upon the patient's right leg.  She was prepped and draped in the usual sterile manner.  The limb was elevated and exsanguinated and tourniquet placed 325 mmHg for the above noted time.  A straight incision was carried down through the skin and subcutaneous tissue.  Hemostasis was controlled with electrocoagulation.  Medial parapatellar arthrotomy was created and the knee cap was everted.  The ligaments were balanced.  A portion of the fat pad was removed and the ACL was completely removed.  Drill hole was made in the distal femur.  The size to an E, right.  Care was taken to make up for the severe loss of articular cartilage on the posterior condyle in the lateral side.  This was checked with the epicondylar abscess and with three degrees of external rotation, drill holes were made.  Intramedullary guide was then placed, pegged, and anterior cut carried out.  There was excellent resection.  It was flat.  Distal cutting guide was then placed in five degrees of valgus.  Appropriate cuts were carried out.  The standard cut was utilized.,The finishing guide for E was held with pins as well as screws.  Cutting was carried out posterior to anterior, then posterior chamfer and anterior chamfer, femoral sulcus cut was carried out and drill holes for pegs were made.  The cutting guide was then removed.  The bone was removed.  Excess bone was taken out posteriorly.  The posterior capsule was loosened up.  There were two different fabellas in the posterolateral compartment and they were loosened.  Posterolateral corner was then anchored with osteotome and was taken around the posterolateral corner.  An extramedullary tibial cutting guide was then placed, pinned, and held.  A cut was carried out parallel to the foot.  Hard copy ________ was obtained, deemed to be satisfactory after evening up the edges.  Trial range of motion was satisfactory.  It was necessary to perform a lateral retinacular release to the patella.  The patella was isolated.  Approximately 10 mm to 11 mm were reamed off.  The size to 32 mm button and drill hole guide was placed, impacted, and drilled.  Trial range of motion was satisfactory.  The tibial guide was then pinned.  Drill hole was placed, broached, and utilized.  Copious irrigation was carried out.  Methylmethacrylate was mixed and was sequentially placed from the femur to the tibia to the patella.  The implants were sequentially placed in tibia to femur to patella.  Once excess methylmethacrylate was removed and cured, 10 mm Poly was placed.  There was excellent ligament balancing.  A separate portal was utilized for subcutaneous drain.  Tourniquet was deflated and hemostasis was controlled with electrocoagulation.  Interrupted #1 Ethibond suture was utilized for parapatellar closure, running #1 Vicryl suture was utilized for overstitch.,Trial range of motion was satisfactory.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed to the skin.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were pink and warm with brawny pulses distally at the end of the case.  The patient was then transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.",Total Knee Arthroplasty,Orthopedic,"orthopedic, arthroplasty, knee, degenerative osteoarthritis, subcutaneous, osteoarthritis, degenerative, tourniquet, drill,"
Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only.  He has been referred for cardiac catheterization.,"The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.",Cardiac Catheterization - 11,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac,"
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.,"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.",Barium Swallow Study & Speech Evaluation,Gastroenterology,
Left third digit numbness and wrist pain.,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",MRI C3 - Cord Compression.,Radiology,
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.,"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.",Ventricular Ectopy - Consult,Cardiovascular / Pulmonary,
MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",MRI T-L Spine - Schistosomiasis,Orthopedic,
A middle-aged male with increasing memory loss and history of Lyme disease.,"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.",MRI Brain - Lyme Disease,Neurology,"neurology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,"
Fall with questionable associated loss of consciousness.  Left parietal epidural hematoma.,"CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, ""Ginsana"" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.",Epidural Hematoma,Neurology,"neurology, loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,"
"Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.","PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.",Osteotomy & Bunionectomy,Orthopedic,
2-month-old female - increased work of breathing.,"CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.",Bronchiolitis - 2-month-old,Cardiovascular / Pulmonary,
"Lumbar muscle strain and chronic back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.","HISTORY OF PRESENT ILLNESS:,  Patient is a 50-year-old white male complaining of continued lower back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.  He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he ""felt it"" in his lower back.  The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients.  He feels that this aggravated his chronic back pain as well.  He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture.  He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain.  He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs.  Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X.  He was given a prescription for 12 Vicodin as well as some to take home last night.  The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend.  Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines.  He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:,  HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse is elevated at 105.  Temp and other vitals signs are all within normal limits.,GENERAL:  Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK:  Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left.  There is a well-healed upper lumbar incision from his previous L1-L2 fusion.  There is no erythema, ecchymosis, or soft-tissue swelling.  Mobility is generally very good without obvious signs of discomfort.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL:  With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg.  There is some mild discomfort on internal and external rotation of the hips as well.  DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a ""good day.""  I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a ""bad day,"" he will have nowhere else to turn.  I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night.  It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night.  I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night).  I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping.  The patient is agreeable to this.,ASSESSMENT,1.  Lumbar muscle strain.,2.  Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible.  Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex.  He may continue with his other medications as directed but not the methadone or Darvocet.  I did urge him to reschedule his pain clinic appointment as he was urged to do originally.  If unimproved this week, he should follow up with Dr. Y.",Lower back pain,Orthopedic,"orthopedic, back pain, lumbar muscle strain, chronic back pain, illness, lower, medications,"
"Renal failure evaluation for possible dialysis therapy.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.","REASON FOR CONSULTATION:,  Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally.  He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids.  While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now.  He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder.  He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9.  Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1.  He did not put out any significant urine and his weight was documented at 103 kg.  He was given a dose of Kayexalate.  His potassium came down to like about 5.9 and urine studies were ordered.  His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria.  He did have a low albumin of 1.9.  He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems.  He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care.  He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired.  He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain.  He did have a decrease in his appetite, which all started about Thursday.  We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy.  He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married.  He does smoke despite understanding the risks associated with smoking a pack every 6 days.  Does not drink alcohol or use any recreational drug use.  He was on no prescribed medications.  He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General:  He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm without a rub.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.,Extremities:  Showed no clubbing, cyanosis.  He did have 2+ pretibial edema in both lower extremities.,Neurologic:  No gross focal findings.,Skin:  Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute.  Calcium 7.4 with an albumin of 1.9.  Mag normal at 2.2.  Urine culture negative at 12 hours.  His Random urine sodium was low at 12.  Random urine protein was 4756, and creatinine in the urine was 538.  Urine drug screen was unremarkable.  Troponin was within normal limits.  Phosphorus slightly elevated at 5.7.  CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs.  PT 10.0, INR 1.0, PTT at 27.3.  B-natriuretic peptide 718.  Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2.  Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3.  Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4.  Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2.  I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable.  We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention.  We will also give him 10 mg of Zaroxolyn p.o.  Discontinue all IV fluids.  Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level.  I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job.  I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult.  I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.",Renal Failure Evaluation,Nephrology,
"Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.","CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,",Heart Catheterization & Angiography - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,"
Psychiatric consultation of patient with lethargy.,"REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being ""fine,"" participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.",Psych Consult - Lethargy,Psychiatry / Psychology,
"Congestion, tactile temperature.","CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.",Congestion - 21-day-old,Pediatrics - Neonatal,
"Intractable epilepsy, here for video EEG.","CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.",Intractable Epilepsy,Neurology,"neurology, brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg,"
"Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.  While playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.","HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.",Knee Injury,Orthopedic,"orthopedic, acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior,"
The patient had tympanoplasty surgery for a traumatic perforation of the right ear about six weeks ago.,"The right eardrum is intact showing a successful tympanoplasty.  I cleaned a little wax from the external meatus.  The right eardrum might be very slightly red but not obviously infected.  The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  Also some wax at the external meatus I cleaned with a Q-tip with peroxide.  The patient has no medical allergies.  Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens.  I looked at this throat which looks clear.  The nose only has a little clear mucinous secretions.  If there is any ear drainage, please use the Floxin drops.  I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  I plan to see the patient again later this spring.",Status Post Tympanoplasty,ENT - Otolaryngology,"ent - otolaryngology, tympanoplasty surgery, traumatic perforation, external meatus, wax, external, perforation, eardrum, meatus, tympanoplasty, earNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.","PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.",Hallux Infected Bone Resection,Orthopedic,"orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,"
A 51-year-old male with chest pain and history of coronary artery disease.,"COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.",Coronary CT Angiography (CCTA) - 6,Cardiovascular / Pulmonary,
Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.,"PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.",Pituitary Adenomectomy,Neurosurgery,
Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain,"DISCHARGE DIAGNOSES:,1.  Chest pain.  The patient ruled out for myocardial infarction on serial troponins.  Result of nuclear stress test is pending.,2.  Elevated liver enzymes, etiology uncertain for an outpatient followup.,3.  Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia.  The patient ruled out for myocardial infarction with serial troponins.  Nuclear stress test has been done, results of which are pending.  The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations.  He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks.  Discharge medications will depend on results of nuclear stress test.",Chest Pain - Office Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test"
"Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.","PREPROCEDURE DIAGNOSIS: , Abdominal pain, diarrhea, and fever.,POSTPROCEDURE DIAGNOSIS: , Pending pathology.,PROCEDURES PERFORMED: , Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.",Colonoscopy with Biopsy - 3,Gastroenterology,"gastroenterology, colonoscopy with multiple biopsies, length of the colon, diarrhea and fever, terminal ileum cecum, multiple biopsies, ileum cecum, cecum hepatic, hepatic flexure, terminal ileum, sigmoid colon, colonoscopy, diarrhea, cecum, hepatic, flexure, inflammation, biopsies, terminal, ileum, sigmoid, scope,"
Patient with right ankle pain.,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",MRI Ankle - 1,Radiology,
Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",Falls - Discharge Summary,Psychiatry / Psychology,
"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.","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.",Triple Lumen Catheter Insertion - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire"
"Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.","PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.",Port-A-Cath Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire,"
A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation.,"HISTORY OF PRESENT ILLNESS:,  This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant.  The patient did well after the liver transplant and the only problems started:,1.  History of food allergies.,2.  History of dental cavities.,At this time, the patient came for a followup and is complaining of a left upper molar pain.  There are no other complaints.,DIET: , Lactose-limited diet.,MEDICATIONS: , Please see the MRC form.,ALLERGIES: , There are no allergies.,SOCIAL HISTORY:,  The patient lives with the parents in Lindsay, California and has a good environment.,FAMILY HISTORY: , Negative for gastrointestinal illness except that a sibling has ulcerative colitis.,REVIEW OF SYSTEMS: , The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,PHYSICAL EXAMINATION:  ,MEASUREMENTS:  Height 135 cm and weight 28.1 kg.,VITAL SIGNS:  Temperature 98.9 and blood pressure 105/57.,GENERAL:  A well-developed, well-nourished child in no acute distress.,HEENT:  Atraumatic and normocephalic.  The pupils are equal, round, and reactive to light.  Full EOMs.  The conjunctivae and sclerae are clear.  The TMs show normal landmarks.  The nasal mucosa is pink and moist.  The teeth and gums are in good condition.  The pharynx is clear.,NECK:  Supple, without thyromegaly and without masses.,LYMPHATIC:  No adenopathy.,LUNGS:  Clear to auscultation, with no retractions.,CORONARY:  Regular rhythm without murmur.  S1 and S2 are normal.  The pulses are full and symmetrical bilaterally.,ABDOMEN:  Normal bowel sounds.  No hepatosplenomegaly, no masses, and no tenderness.,GENITALIA:  Normal female by inspection.,SKIN:  No unusual lesions.,BACK:  No scoliosis, hairy patch, lipoma, or sacral dimple.,EXTREMITIES:  No cyanosis, clubbing, or edema.,CENTRAL NERVOUS SYSTEM:  Developmentally appropriate for age.  DTRs are 2+ and symmetrical.  The toes are downgoing bilaterally.  Motor and sensory without asymmetry.  Cranial nerves II through XII are grossly intact.,LABORATORY DATA:,  Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected.,FINAL IMPRESSION:,  This is a 10-year-old with history of:,1.  Biliary atresia.,2.  Status post orthotopic liver transplantation.,3.  Dental cavities.,4.  Food allergies.,5.  History of urinary tract infections.,PLAN: , Our plan would be to continue with the medications as follows:,1.  Prograf 0.5 mg p.o. b.i.d.,2.  Valganciclovir 420 mg p.o. b.i.d.,3.  Labs every 2 to 3 months.,4.  To return to clinic in 4 months.,5.  To refer this patient to a pediatric dentist for assessment of the dental cavities.",Status Post Liver Transplant,Gastroenterology,
CT of Lumbar Spine without Contrast.  Patient with history of back pain after a fall.,"EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:,  Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation.  There is no spondylolysis or spondylolisthesis.  The central canal and neuroforamen are grossly patent at all levels.  There are no abnormal paraspinal masses. There is no wedge/compression deformity.  There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated.  There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1.  No evidence for acute fracture or subluxation.,2.  Mild degenerative changes.,3.  Probable left simple renal cyst.,",CT of Lumbar Spine w/o Contrast,Orthopedic,"orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,"
"Left and right heart catheterization and selective coronary angiography.  Coronary artery disease, severe aortic stenosis by echo.","INDICATION:,  Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Right heart catheterization.,3.  Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in usual sterile fashion.  After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein.  Then right heart cath was performed using 7-French Swan-Ganz catheter.  Catheter was placed in the pulmonary capillary wedge position.  Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained.  The right heart catheter _______ pulled out.  Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter.  Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful.  After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  The patient tolerated the procedure well.  There were no complications.,HEMODYNAMICS:,1.  Cardiac output was 4.9 per liter per minute.  Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.,2.  Coronary angiography, left main is calcified _______ dense complex.,3.  LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis.  Left circumflex has diffuse luminal irregularities.  OM1 has 70% stenosis, is a moderate-size vessel.  Right coronary is dominant and has minimal luminal irregularities.,SUMMARY: , Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.,RECOMMENDATION: , Aortic valve replacement with coronary artery bypass surgery.",Heart Catheterization & Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary"
"Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.","PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.",Laryngoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,"
"A white female who presents for complete physical, Pap and breast exam.","SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.",Physical Exam and Pap -3,Obstetrics / Gynecology,
Patient complains of constipation.  Has not had BM for two days.,"Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,",Constipation - 1,Gastroenterology,"gastroenterology, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,"
"Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.","PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.",Craniotomy - Biparietal,Neurosurgery,"neurosurgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,"
Abnormal EKG and rapid heart rate.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,"REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female.  From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  The patient relates to have some low-grade fever.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  As per the medications, they are not very clear.  Husband has gone out to brief her medications.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol status is normal.  Questionable history of coronary artery disease.  Family history noncontributory.,FAMILY HISTORY:,  Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR:  Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY:  Shortness of breath, questionable pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, no vomiting, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,SKIN:  Nonsignificant.,PSYCHOLOGIC:  Anxiety and depression.,ALLERGIES:  Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK:  Neck is supple.  Atraumatic and normocephalic.  Neck veins are flat.  No thyromegaly.,LUNGS:  Air entry bilaterally fair.  Decreased breath sounds especially in the right basilar areas.  Few crackles.,HEART:  Normal S1 and S2, irregular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulse is palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes.  INR of 4.5, H and H 10 and 30.  BUN and creatinine are within normal limits.  Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1.  The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  Symptoms as above.,RECOMMENDATIONS:,1.  We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  Once, if she is stable, we will consider further cardiac workup.,2.  We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.",Consult - Abnormal EKG,Cardiovascular / Pulmonary,
"Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.","PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.",D&C & Hysteroscopy - 1,Obstetrics / Gynecology,"obstetrics / gynecology, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,"
CT scan of the abdomen and pelvis without and with intravenous contrast.,"EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.",CT Abdomen & Pelvis - 2,Gastroenterology,"gastroenterology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,"
Initial obstetrical examination - Normal first pregnancy.  Inadequate naternal nutrition.,"CHIEF COMPLAINT,:  This 32 year-old female presents today for an initial obstetrical examination.  Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).  LMP:  02/13/2002 EDD:  11/20/2002 GW:  8.0 weeks.  Patient has been trying to conceive for 6 months.,Menses:  Onset:  12 years old.  Interval:  24-26 days.  Duration:  4-6 days.  Flow:  moderate.  Complications:  PMS - mild.,Last Pap smear taken on 11/2/2001.  Contraception:  Patient is currently using none.,ALLERGIES:,  Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, severe rash, pet dander resulting in nasal stuffiness.  Medication History:  None.,PAST MEDICAL HISTORY:,  Past medical history is unremarkable.  Past Surgical History:  Patient admits past surgical history of tonsillectomy in 1980.  Social History:  Patient admits alcohol use Drinking is described as social, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:,  Patient admits a family history of cancer of breast associated with mother.,REVIEW OF SYSTEMS:,Neurological: (+) unremarkable.,Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms.,Psychiatric: (+) anxious feelings.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Genitourinary: (-) decreased libido, (-) vaginal dryness, (-) vaginal bleeding.  Diet is high in empty calories, high in fats and low in fiber.,PHYSICAL EXAM:,  BP Standing:  126/84 Resp:  22 HR:  78 Temp:  99.1 Height:  5 ft.  6 in.  Weight:  132 lbs.,Pre-Gravid Weight is 125 lbs.,Patient is a 32 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.,Oriented to person, place and time.,Mood and affect normal and appropriate to situation.,HEENT:Head & Face:  Examination of head and face is unremarkable.,Skin:  No skin rash, subcutaneous nodules, lesions or ulcers observed.  No edema observed.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Respiratory:  Lungs CTA.,Breast:  Chest (Breasts):  Breast inspection and palpation shows no abnormal findings.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.,Genitourinary:  External genitalia are normal in appearance.  Examination of urethra shows no abnormalities.  Examination of vaginal vault reveals no abnormalities.  Cervix shows no pathology.  Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.  Adnexa and parametria show no masses, tenderness, organomegaly or nodularity.  Examination of anus and perineum shows no abnormalities.,TEST RESULTS: , Urine pregnancy test:  positive. CBC results within normal limits.  Blood type:  O positive.  Rh:  positive.  FBS:  88 mg/dl.,IMPRESSION:,  Pregnancy, normal first.  Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets.,PLAN:,  Pap smear submitted for manual screening.  Ordered CBC.  Ordered blood type.  Ordered hemoglobin.  Ordered Rh.,Ordered fasting blood glucose.,COUNSELING:,  Counseling was given regarding adverse effects of alcohol, physical activity and sexual activity.  Educational supplies dispensed to patient.,Return to clinic in 4 week (s).,PRESCRIPTIONS:,  NatalCare Plus Dosage:  Prenatal Multivitamins tablet Sig:  QD Dispense:  60 Refills:  4 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient received written information regarding pre-eclampsia and eclampsia.  Patient was instructed to restrict activity.  Patient instructed to limit caffeine use.  Patient instructed to limit salt intake.",OB/GYN - H&P,Obstetrics / Gynecology,
"Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.","PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.",Anterior Cervical Discectomy & Arthrodesis - 2,Neurosurgery,"neurosurgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,"
"The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.","HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.",Consult - Migraine,Neurology,
A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,"PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.",Mantle Cell Lymphoma,Hematology - Oncology,
Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.",Bilateral Carotid Cerebral Angiogram,Neurology,"neurology, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
Psychiatric Consultation of patient with major depression disorder.,"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.",Psych Consult - Depression - 2,Psychiatry / Psychology,
"Well-child check sports physical - Well child asthma with good control, allergic rhinitis.","CHIEF COMPLAINT:,  Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:,  This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis.  He is here with his mother for a well-child check.  Mother states he has been doing well with regard to his asthma and allergies.  He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed.  His last exacerbation was 04/04.  He has been very competitive in his sports this spring and summer and has had no issues since that time.  He eats well from all food groups.  He has very good calcium intake.  He will be attending Maize High School in the ninth grade.  He has same-sex and opposite-sex friends.  He has had a girlfriend in the past.  He denies any sexual activity.  No use of alcohol, cigarettes or other drugs.  His bowel movements are without problems.  His immunizations are up to date.  His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:,  As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional:  He has had no fever.,HEENT:  No vision problems.  No eye redness, itching or drainage.  No earache.  No sore throat or congestion.,Cardiovascular:  No chest pain.,Respiratory:  No cough, shortness of breath or wheezing.,GI:  No stomachache, vomiting or diarrhea.,GU:  No dysuria, urgency or frequency.,Hematological:  No excessive bruising or bleeding.  He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress.,Vital signs:  He is afebrile.  His weight is at the 75th percentile.  His height is about the 80th percentile.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal, round and reactive to light.  TMs are clear bilaterally.  Nares patent.  Nasal mucosa is mildly edematous and pink.  No secretions.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Good air exchange bilaterally.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Male.  Testes descended bilaterally.  Tanner IV.  No hernia appreciated.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  Minor sunburn on upper back.,Neurological:  Grossly intact.,ASSESSMENT:,1.  Well child.,2.  Asthma with good control.,3.  Allergic rhinitis, stable.,PLAN:,  Hearing and vision assessment today are both within normal limits.  Will check an H&H today.  Continue all medications as directed.  Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue.  Anticipatory guidance for age.  He is to return to the office in one year or sooner if needed.",Sports Physical - 3,Pediatrics - Neonatal,
"Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.","PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.",Ulnar Nerve Transposition,Neurology,"neurology, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve"
"Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.","SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.",SOAP - Lung Mass,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,"
"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.","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:",Bipolar Affective Disorder - Consult,Psychiatry / Psychology,
Laparoscopic supracervical hysterectomy.  A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.,"PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.",Laparoscopic Supracervical Hysterectomy.,Obstetrics / Gynecology,"obstetrics / gynecology, adnexa, uterus, laparoscopic supracervical hysterectomy, veress needle, bladder flap, cardinal ligament, uterine, cauterized, dysmenorrhea, menorrhagia,"
Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.",Thoracic Discectomy,Neurosurgery,"neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,"
"Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".","CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and ""Right upper lobe lung"".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.",Lung adenocarcinoma Path Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,"
Psychosocial Evaluation of patient before kidney transplant.,"HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.",Psychosocial Eval for Kidney Transplant,Nephrology,
"A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.","CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.",Reactive Airway Disease,Cardiovascular / Pulmonary,
"Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.","PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.",Chest Tube Placement,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest,"
"Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.","PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.",Dual Chamber ICD Implantation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,"
A white female presents for exam and Pap.,"SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",Physical Exam and Pap - 1,Obstetrics / Gynecology,
Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.,"PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.",Abdominal Exploration,Gastroenterology,"gastroenterology, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic"
Left knee arthroscopy with lateral capsular release.,"PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.",Knee Arthroscopy,Orthopedic,"orthopedic, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,"
A 27-year-old female with a size and date discrepancy.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:",Ultrasound OB - 7,Radiology,
MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",MRI Brain - SLE & Stroke,Neurology,
"Bronchoscopy brushings, washings and biopsies.  Patient with a bilateral infiltrates, immunocompromised host, and pneumonia.","OPERATIVE PROCEDURE:,  Bronchoscopy brushings, washings and biopsies.,HISTORY: , This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate, immunocompromise.,INDICATIONS FOR THE PROCEDURE:,  Bilateral infiltrates, immunocompromised host, and pneumonia.,Prior to procedure, the patient was intubated with 8-French ET tube orally by Anesthesia due to her profound hypoxemia and respiratory distress.,DESCRIPTION OF PROCEDURE: , Under MAC and fluoroscopy, fiberoptic bronchoscope was passed through the ET tube.,ET tube was visualized approximately 2 cm above the carina.  Fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  The patient tolerated the procedure well.  Postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  Specimens are sent for immunocompromise panel including PCP stains.,POSTPROCEDURE DIAGNOSIS:,  Pneumonia, infiltrates.",Bronchoscopy Brushings,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mac, fluoroscopy, fiberoptic bronchoscope, bronchoscopy brushings, fiberoptic, bronchoscope, bronchoscopy, biopsies, pneumonia, immunocompromised"
Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,"TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.",Youngswick Osteotomy,Orthopedic,"orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy"
Gastroscopy.  Dysphagia and globus.  No evidence of inflammation or narrowing to explain her symptoms.,"PROCEDURE:,  Gastroscopy.,PREOPERATIVE DIAGNOSIS:,  Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  The preparation was good and all surfaces were well seen.  The hypopharynx was normal with no evidence of inflammation.  The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's.  Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  The scope was withdrawn and the patient was sent to recovery room.  She tolerated the procedure well.,FINAL DIAGNOSES:,1.  Normal post-gastric bypass anatomy.,2.  No evidence of inflammation or narrowing to explain her symptoms.",Gastroscopy - 2,Gastroenterology,"gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation"
Right upper quadrant pain.  Nuclear medicine hepatobiliary scan.  Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,"NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.",Hepatobiliary Scan,Gastroenterology,"gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine"
Microsuspension direct laryngoscopy with biopsy.  Fullness in right base of the tongue and chronic right ear otalgia.,"PREOPERATIVE DIAGNOSES:,1.  Fullness in right base of the tongue.,2.  Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:,  This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side.  Exact etiology of her ear pain had not been identified.  A fiberoptic examination had been performed in the office.  Upon examination, she was noted to have fullness in the right base of her tongue.  She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position.  General endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where a shoulder roll was placed.  A tooth guard was then placed to protect the upper dentition.  The Dedo laryngoscope was then inserted into the oral cavity.  It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view.  At this point, it was advanced underneath the epiglottis until the vocal cords were seen.  At this point, it was suspended via the Lewy suspension arm from the Mayo stand.  At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field.  Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities.  It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified.  This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle.  At this point, the scope was desuspended and the microscope was removed.  The scope was withdrawn through the vallecular region.  Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable.  Biopsies were obtained with straight-biting cup forceps.  Once hemostasis was achieved, the scope was advanced into the piriform sinuses.  Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus.  Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall.  There were no mucosal abnormalities identified within the oropharynx.  The scope was then completely removed and a bimanual examination was performed.  No neck masses were identified.  At this point, the procedure was complete.  The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.",Microsuspension Direct Laryngoscopy & Biopsy,ENT - Otolaryngology,"ent - otolaryngology, microsuspension, laryngoscopy, otalgia, ear pain, fiberoptic, dedo laryngoscope, epiglottis, direct laryngoscopy, piriform sinuses, tongue, microscope, mucosal, abnormalities, fullness, ear, scope"
2-D Echocardiogram,"2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.",2-D Echocardiogram - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.","PREOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,OPERATIONS,1.  Right common carotid endarterectomy.,2.  Right internal carotid endarterectomy.,3.  Right external carotid endarterectomy.,4.  Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:,  General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the right neck was prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors.  The common, internal and external carotid arteries were identified.  The facial vein was ligated with #3-0 silk.  The hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  After dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  Next, an umbilical tape was passed around the common carotid artery.  A #0 silk suture was passed around the internal and external carotid arteries.  The hypoglossal nerve was identified and preserved.  An appropriate sized Argyle shunt was chosen.  A Hemashield patch was cut to the appropriate size.  Next, vascular clamps were placed on the external carotid artery.  DeBakey pickups were used to control the internal carotid artery and common carotid artery.  A #11-blade scalpel was used to make an incision on the common carotid artery.  The arteriotomy was lengthened onto the internal carotid artery.  Next, the Argyle shunt was placed.  It was secured in place.  Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  An inversion technique was used on the external carotid artery.  The artery was irrigated and free debris was removed.  Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion.  Prior to completion of our anastomosis, we removed our shunt.  We completed the anastomosis.  Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  There was no evidence of bleeding.  Full-dose protamine was given.  The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion.  A sterile dressing was applied.",Carotid Endarterectomy - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy"
Transesophageal echocardiogram and direct current cardioversion.,"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.",Transesophageal Echocardiogram,Cardiovascular / Pulmonary,
A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.,"HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.",Sickle Cell Anemia - ER Visit,Hematology - Oncology,
Bilateral temporal artery biopsy.  Rule out temporal arteritis.,"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.",Temporal Artery Biopsy,Neurosurgery,"neurosurgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis"
"Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.","PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.",Phenol Neurolysis & Botulinum Toxin Injection - 1,Neurology,"neurology, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol"
Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,"PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.",Eyelid Squamous Cell Carcinoma Excision,Hematology - Oncology,"hematology - oncology, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,"
"Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.","PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.",Toronto Porcine Valve Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,"
Subcutaneous transposition of the right ulnar nerve.  Right carpal tunnel syndrome and right cubital tunnel syndrome.,"PREOPERATIVE DIAGNOSIS:  ,1.  Right carpal tunnel syndrome.,2.",Subcutaneous Transposition of Ulnar Nerve,Orthopedic,"orthopedic, subcutaneous transposition, ulnar nerve, carpal tunnel syndrome, cubital tunnel syndrome, tourniquet, subcutaneous, epicondyle, antebrachial, syndrome, cubital, ulnar, nerve, tunnel"
"Uvulopalatopharyngoplasty and tonsillectomy.   The patient with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.","PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS:  ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1.  Tonsillectomy.,2.  Uvulopalatopharyngoplasty.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity.  Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole.  The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed.  Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  Now attention was directed to the posterior pillars.  A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors.  The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate.  Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  The mucosa was dissected off with the use of Potts scissors.  Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers.  Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures.  Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate.  A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars.  Final inspection did not reveal any further bleeding.  The mouth was then irrigated with saline and suctioned.  At this point, the procedure was complete.  He was awakened and taken to recovery room in stable condition.  He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management.  Of note, IV Decadron was administered during the procedure.",Uvulopalatopharyngoplasty & Tonsillectomy,ENT - Otolaryngology,"ent - otolaryngology, endotracheal, metzenbaum, soft palate, obstructive sleep apnea, tonsillectomy, uvulopalatopharyngoplasty, obstructive, mucosa, uvula, palate,"
A female for a complete physical and follow up on asthma with allergic rhinitis.,"SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.",Followup on Asthma,Cardiovascular / Pulmonary,
"Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.","PROCEDURE: , Sigmoidoscopy.,INDICATIONS:,  Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:,  A history and physical examination were performed.  The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this.  Opportunity for questions was provided and informed consent obtained.  After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm.  Careful inspection was made as the sigmoidoscope was withdrawn.  The quality of the prep was good.  The procedure was stopped due to patient discomfort.  The patient otherwise tolerated the procedure well.  There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries.  Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.",Sigmoidoscopy - 1,Gastroenterology,"gastroenterology, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,"
"Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.","PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.",Fat Harvesting,ENT - Otolaryngology,"ent - otolaryngology, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh"
"Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.","OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was 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.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in 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 was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.",CABG - Redo,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,"
Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,"PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:,  Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:,  C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions.  A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy.  After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees.  A shoulder roll was placed and the head supported on a donut support.  The cervical region was prepped and draped in the standard fashion.  A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy.  Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint.  On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  This was done under the microscope.  A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level.  This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  With this done, the wound was irrigated.  Hemostasis was ensured with bipolar coagulation.  Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites.  Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed.  A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7.  The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7.  With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch.  Steri-Strips and sterile dressings were applied.  The patient remained hemodynamically stable throughout the procedure.  Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure.  The patient remained stable throughout the procedure.",Anterior Cervical Discectomy - 3,Neurosurgery,"neurosurgery, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,"
Lysis of pelvic adhesions.  The patient had an 8 cm left ovarian mass.   The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.,"PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.",Lysis of Pelvic Adhesions,Obstetrics / Gynecology,"obstetrics / gynecology, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,"
"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.","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.",Thrombectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,"
Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.,"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.",Tessio Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,"PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.",Pacemaker Interrogation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,"
Left third digit numbness and wrist pain.,"CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.",MRI C3 - Cord Compression.,Orthopedic,
Ultrasound - a 22-year-old pregnant female.,"GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:",Ultrasound OB - 6,Obstetrics / Gynecology,"obstetrics / gynecology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal,"
MRI demonstrated right contrast-enhancing temporal mass.,"SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.",SOAP - Temporal Mass,Neurology,"neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE"
This is a middle-aged female with two month history of low back pain and leg pain.,"FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:",CT Lumbar Spine - 2,Neurology,"neurology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet"
Psychiatric consultation of patient with lethargy.,"REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being ""fine,"" participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.",Psych Consult - Lethargy,Psychiatry / Psychology,
A 16-year-old male with Q-fever endocarditis.,"HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.",Q-Fever Endocarditis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,"
"Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.","PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.",Phacoemulsification & Cataract Extraction - 1,Ophthalmology,"ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens"
A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.,"COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.",Coronary CT Angiography (CCTA) - 3,Radiology,
Psychosocial evaluation of kidney donor.  Questions - Answers,"DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - ""This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant."",When and how did subject of donation arise - ""My mom and I talked about it together as a family."",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  ""I would rather not go there.  Well, since we were talking, ""I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting."",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - ""Well, my children are fine and my husband is very supportive."",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - ""My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate."",How would your family and friends react if you decided not to be a donor - ""I don't think that is going to happen."",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - ""I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup."",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - ""That is my mother."",How your relationship with the recipient change if you donate your kidney - ""I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others."",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - ""Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process."",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - ""Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things."",Have you thought about how you might feel if the kidney is rejected - ""I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this."",Do you have any doubts or concerns about donating - ""No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - ""Of course, I do."",What are your expectations about your recuperation - ""I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us."",Do you need to speak further to any of the transplant team members - ""No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - ""I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health."",Are you currently on any medication - ""Yes, I am on Folic acid."",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - ""No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to."",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - ""No."",Any typical drinks you prefer - ""I am a nondrinker."",What kinds of recreational drugs have you tried?  Have you used any recently - ""None."",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  ""I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years."",NAME OF SPOUSE/PARTNER:  ""His name is Xyz."",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college."",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - ""I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup."",CURRENT OCCUPATION:,What is your current occupation - ""I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom."",Do you have the support of your employer - ""Absolutely."",PAID OFF TIME:,Paid leave - ""None."",Disability coverage:  ""None."",SUPPORTIVE ENVIRONMENT:,  ""Yes.""",Psychosocial Eval - Donor,Psychiatry / Psychology,
Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.,"HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.",Hyperfractionation,Hematology - Oncology,"hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Patient with dysphagia.,"PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.",Endoscopy - 3,Gastroenterology,"gastroenterology, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon"
A sample note on bilateral myringotomy tubes,"Parents often ask why the fluid cannot be drained without inserting a tube.  The need for the tube insertion is because the eardrum incision generally heals very rapidly (within a few days), which is not long enough for the swollen membranes in the middle ear to return to normal.  As soon as the eardrum heals, fluid will reaccumulate.  Tubes were first introduced because of this very problem.  There are many types of tubes, but all tubes serve the same function.  They keep the eardrum open, allow air to enter the middle ear space, and permit fluid in the middle ear to drain.  Most tubes will gradually be rejected by the ear and work their way out of the eardrum.  As they come out, the eardrum seals behind the tube.  Tubes will last four to six months in the eardrum before they come out.  Occasionally, the eardrum does not heal completely when the tube comes out.,The majority of children treated with tubes do not require further surgery.  They may have ear infections in the future, but most will clear up with medical treatment.  Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection.  Children tend to outgrow this cycle by age 7 or 8.  In an ear, nose and throat specialty practice, this group comprises 10 to 15% of all children who have required tubes.  Occasionally the physician has to physically remove the tube from the ear drum.",BMT - Bilateral Myringotomy Tubes,ENT - Otolaryngology,"ent - otolaryngology, eardrum, myringotomy, tubes, bilateral myringotomy tubes, myringotomy tubes, ear infections, middle ear, fluid, childrenNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.,"EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.",CT Abdomen & Pelvis - OB-GYN,Obstetrics / Gynecology,"obstetrics / gynecology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen"
A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours.,"REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours.  However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion.  She had also complained of blurred vision for several days.  She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet.  ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS:  ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies.  CBC was normal, aside from a hemoglobin of 11.2.  ECG showed atrial fibrillation.  BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented.  She has some impairment of recent memory.  She is not dysphasic, or apraxic.  Speech is normal and clear.  The head is noted to be normocephalic.  Neck is supple.  Carotid pulses are full bilaterally, with left carotid bruit.  Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold.  Motor examination shows no drift of the outstretched arms.  There is no tremor or past-pointing.  Finger-to-nose and heel-to-shin performed well bilaterally.  Motor showed intact neuromuscular tone, strength, and coordination in all limbs.  Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout.  Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit.  She also has atrial fibrillation, apparently chronic.  In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:,  I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy.  In view of her age, I would be reluctant to recommend Coumadin anticoagulation.  I will be happy to follow the patient with you.",TIA - Cosult,Neurology,"neurology, atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign,"
Excisional biopsy of right cervical lymph node.,"PREOPERATIVE DIAGNOSIS: , Cervical lymphadenopathy.,POSTOPERATIVE DIAGNOSIS:,  Cervical lymphadenopathy.,PROCEDURE: , Excisional biopsy of right cervical lymph node.,ANESTHESIA: , General endotracheal anesthesia.,SPECIMEN: , Right cervical lymph node.,EBL: , 10 cc.,COMPLICATIONS: , None.,FINDINGS:,  Enlarged level 2 lymph node was identified and removed and sent for pathologic examination.,FLUIDS: , Please see anesthesia report.,URINE OUTPUT: , None recorded during the case.,INDICATIONS FOR PROCEDURE: , This is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy.  She reports that it is painful to palpation on the right and has had multiple CT scans as well as an FNA which were all nondiagnostic.  After risks and benefits of surgery were discussed with the patient, an informed consent was obtained.  She was scheduled for an excisional biopsy of the right cervical lymph node.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in the supine position.  She was anesthetized with general endotracheal anesthesia.  The neck was then prepped and draped in the sterile fashion.  Again, noted on palpation there was an enlarged level 2 cervical lymph node.,A 3-cm horizontal incision was made over this lymph node.  Dissection was carried down until the sternocleidomastoid muscle was identified.  The enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to Pathology for touch prep evaluation.  The area was then explored for any other enlarged lymph nodes.  None were identified, and hemostasis was achieved with electrocautery.  A quarter-inch Penrose drain was placed in the wound.,The wound was then irrigated and closed with 3-0 interrupted Vicryl sutures for a deep closure followed by a running 4-0 Prolene subcuticular suture.  Mastisol and Steri-Strip were placed over the incision, and sterile bandage was applied.  The patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition.  She will return to the office tomorrow in followup to have the Penrose drain removed.",Biopsy - Cervical Lymph Node,Hematology - Oncology,"hematology - oncology, lymphadenopathy, excisional biopsy, fna, mastisol, penrose drain, cervical, cervical lymph node, endotracheal anesthesia, lymph node, sternocleidomastoid, cervical lymph, lymph, anesthesia,"
"Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.","PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.",Heart Catheterization - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms"
Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.",Pleurocentesis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,"
Flexible bronchoscopy  to evaluate the airway (chronic wheezing).,"PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.",Flexible Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,"
"A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.","ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.",Cardio/Pulmo Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,"
Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,"PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.",Hemivulvectomy,Obstetrics / Gynecology,"obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,"
"Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.","PREOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right knee.,POSTOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right knee.,PROCEDURE:,  Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella.  All components were cemented with Cobalt G.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Less than 60 minutes.,The patient was taken to the Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 51-year-old female complaining of worsening right knee pain.  The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling.  The patient requested surgical intervention and need for total knee replacement.,All risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent.  All risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent.  The patient was given antibiotics preoperatively.,PROCEDURE DETAIL:  ,The patient was taken to the operating suite and placed in supine position on the operating table.  She was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well.  The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh.  Right lower extremity was prepped and draped in sterile fashion.  All extremities were padded prior to this.,The right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case.  A midline incision was made over the right knee and medial parapatellar arthrotomy was performed.  Patella was everted.  The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed.  The posterior cruciate ligament was intact.,There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment.  The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,At the extramedullary tibial guide, an extended cut was made adjusting for her alignment.  Once this was performed, excess bone was removed.  The reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur.  Once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion.  Excess bone was removed.,Next, the tibia was brought anterior and excised to 71 mm.  It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia.  Once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,Next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed.  The knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability.  There was no loosening appreciated.  There is no laxity appreciated along the posterior cruciate ligament.,Once this was performed, the trial components were removed.  The knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being Cobalt G, it was placed on the tibia.  The tibial components were tagged in position and placed on the femur.  The femoral components were tagged into position.  All excess cement was removed ___ placement of patella.  It was tagged in position.  A 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed.  The cement hardened with the knee in full extension, after which any extra cement was removed.,The wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 Vicryl.  Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples.  The patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition.  The patient tolerated the procedure well.",Total Knee Arthoplasty - Right - 1,Orthopedic,"orthopedic, degenerative joint disease, knee, total knee arthroplasty, biomet, cemented, cobalt g, arthoplasty, osteoarthritis, polyethylene, cruciate, ligament, patella, femoral, tibial,"
"Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.","REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.",End Stage Renal Disease - Consult,Nephrology,
Patient with right ankle pain.,"EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a ""high ankle sprain"" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.",MRI Ankle - 2,Radiology,
Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.  Release of first dorsal extensor compartment.,"PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:,  Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS:  ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis.  She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief.  She is presenting today for release of the first dorsal extensor compartment.  She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics.  She was taken to the operating suite under the auspices of Anesthesiology.  She was given a left upper extremity bier block.  Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution.  Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment.  Dissection was carried down through the dermis into the subcutaneous tissue.  The dorsal radial sensory branches were kept out of harm's way.  They were retracted gently to the ulnar side of the wrist.  The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally.  Both the extensor pollices brevis and abductor pollices longus tendons were identified.  There was no pathology noted within the first dorsal extensor compartment.  The wound was irrigated.  Hemostasis was obtained with bipolar cautery.  The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch.  Sterile occlusive dressing was applied along with the thumb spica splint.  The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.",Dorsal Extensor Compartment Release,Orthopedic,"orthopedic, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet,"
Invasive carcinoma of left breast. Left modified radical mastectomy.,"PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.",Radical Mastectomy,Obstetrics / Gynecology,"obstetrics / gynecology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy"
"Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.","REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",Preeclampsia,Obstetrics / Gynecology,
Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.,"CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for ""attention.""  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she ""tripped"" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.",Falls - Discharge Summary,Psychiatry / Psychology,
The patient was referred for evaluation of cataracts bilaterally,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your referral of patient ABC.  The patient was referred for evaluation of cataracts bilaterally.,On examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  Extraocular muscles were intact, visual fields were full to confrontation OU, and applanations are 12 mmHg bilaterally.  There is no relative afferent pupillary defect.  On slit lamp examination, lids and lashes were within normal limits.  The conj is quiet.  The cornea shows 1+ guttata bilaterally.  The AC is deep and quiet and irises are within normal limits bilaterally.  There is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  On dilated fundus examination, cup-to-disc ratio is 0.1 OU.  The vitreous, macula, vessels, and periphery all appear within normal limits.,Impression:  It appears that Ms. ABC' visual decline is caused by bilateral cataracts.  She would benefit from having removed.  The patient also showed some mild guttata OU indicating possible early Fuchs dystrophy.  The patient should do well with cataract surgery and I have recommended this and she agreed to proceed with the first eye here shortly.  I will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,Again, thank you for your kind referral of this kind lady and I will be in touch with you.,Sincerely,,",Ophthalmology - Letter - 1,Ophthalmology,"ophthalmology, extraocular, applanations, slit lamp, visual field, visual, guttata, surgery, cataracts, eye,"
MRI right ankle.,"EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.",MRI Ankle - 2,Orthopedic,"orthopedic, ankle joint, bone, mri, ankle"
MRI report 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.",MRI Cervical Spine - Chiropractic Specific,Orthopedic,"orthopedic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal"
The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 5,Psychiatry / Psychology,
Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.  Status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.,"TITLE OF OPERATION: , Right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage.,INDICATION FOR SURGERY: , The patient is very well known to our service.  In brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  He was taken to the operating room for the orbitozygomatic approach.  Intraoperatively, everything went well without any complications.  The brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the Intensive Care Unit and then was taken to the CT scan, developed a second seizure.  He was given Ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  I had a long discussion immediately with Dr. X and Dr. Y.  We decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  It worried me and I think that we needed to go ahead and take him to the operating room immediately.  The patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  The original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  He was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma.,PREOP DIAGNOSIS:,  Pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage.,POSTOP DIAGNOSIS:,  Intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach.,ANESTHESIA: , General.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  In the supine position, his head was put in a horseshoe without any complications.  The patient tolerated this very well, and the prior incision was immediately opened.  The surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  At this point, this was a life-saving procedure.  We went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  We went ahead and opened the incision and took out the pterional bone flap without any complications.  We immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  So I went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  So we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  We went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  The brain was very relaxed.  We had a very good resection of the actual blood clot, and the brain was very relaxed.  We irrigated thoroughly.  We identified the ventricles.  We went ahead and did a very careful hemostasis with Avitene with thrombin and Gelfoam with thrombin over the next times in doing the procedure.  All this was done very well, and then we lined the cavity with Surgicel, and the Surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  We went ahead and closed back the actual dura back.  We had done a pericranial flap.  This was also put back in place and the dura was closed with 4-0 Surgilons.  We reconstructed everything.  The frontal sinus was reconstructed thoroughly without any complications.  We went ahead and put once again a watertight closure and went ahead and put another piece of DuraGen with Hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  Once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  In summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  So everything was stable.  Estimated blood loss was about 100 cubic centimeters.  The sponges and needle counts were correct.  No specimens were sent to pathology.,DISPOSITION: , The patient after this procedure was brought to the Neuro Intensive Care Unit for close observation.",Craniotomy,Neurosurgery,"neurosurgery, orbitozygomatic, intracranial, brain tumor, intraparenchymal hematoma, orbitozygomatic approach, frontal lobe, intracranial hemorrhage, pituitary tumor, craniotomy, hemorrhage,"
Epicondylitis. history of lupus.  Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.,"SUBJECTIVE:,  The patient is here for a follow-up.  The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d.  Eye report was noted and appreciated.  The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  She denied having any trauma.  She states that the pain is bothering her.  She denies having any fevers, chills, or any joint effusion or swelling at this point.  She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:,  The patient is alert and oriented.  General physical exam is unremarkable.  Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  Hand examination is unremarkable today.  The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:,  Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:,  We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine.  The posterior approach was chosen under sterile conditions.  The patient tolerated both procedures well.  I will obtain CBC and urinalysis today.  If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.",Rheumatology Progress Note,Orthopedic,"orthopedic, rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,"
Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.",Skull Base Reconstruction,Neurosurgery,"neurosurgery, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath"
"Dobutamine stress test for chest pain, as the patient was unable to walk on a treadmill, and allergic to adenosine.  Nondiagnostic dobutamine stress test.   Normal nuclear myocardial perfusion scan.","EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT.",Dobutamine Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, nuclear myocardial perfusion scan, dobutamine stress test, ejection fraction, myocardial perfusion, perfusion scan, dobutamine stress, stress test, myocardial, perfusion, nuclear, dobutamine, stress,"
"Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.","OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was 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.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in 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 was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.",CABG - Redo,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,"
"L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.","PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.",Laminotomy & Microdissection,Neurosurgery,"neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,"
"Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.","REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.",Ischemic Cecum - Consult,Gastroenterology,"gastroenterology, ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia,"
"Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.","INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.",Cardiac Catheterization - 7,Cardiovascular / Pulmonary,
Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor.,"PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.",Craniotomy & Neuronavigation,Neurology,"neurology, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,"
Open cholecystectomy (attempted laparoscopic cholecystectomy).,"PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.",Cholecystectomy - Open,Gastroenterology,"gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,"
Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.,"PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt ""feverish"" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he ""usually"" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL",Proctitis & Proctocolitis,Gastroenterology,
"Excision of basal cell carcinoma.  Closure complex, open wound.  Bilateral capsulectomies.  Bilateral explantation and removal of ruptured silicone gel implants","PREOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,POSTOPERATIVE DIAGNOSES,1.  Basal cell carcinoma, right cheek.,2.  Basal cell carcinoma, left cheek.,3.  Bilateral ruptured silicone gel implants.,4.  Bilateral Baker grade IV capsular contracture.,5.  Breast ptosis.,PROCEDURE,1.  Excision of basal cell carcinoma, right cheek, 2.7 cm x 1.5 cm.,2.  Excision of basal cell carcinoma, left cheek, 2.3 x 1.5 cm.,3.  Closure complex, open wound utilizing local tissue advancement flap, right cheek.,4. Closure complex, open wound, left cheek utilizing local tissue advancement flap.,5.  Bilateral explantation and removal of ruptured silicone gel implants.,6.  Bilateral capsulectomies.,7.  Replacement with bilateral silicone gel implants, 325 cc.,INDICATIONS FOR PROCEDURES,The patient is a 61-year-old woman who presents with a history of biopsy-proven basal cell carcinoma, right and left cheek.  She had no prior history of skin cancer.  She is status post bilateral cosmetic breast augmentation many years ago and the records are not available for this procedure.  She has noted progressive hardening and distortion of the implant.  She desires to have the implants removed, capsulectomy and replacement of implants.  She would like to go slightly smaller than her current size as she has ptosis going with a smaller implant combined with capsulectomy will result in worsening of her ptosis.  She may require a lift.  She is not consenting to lift due to the surgical scars.,PAST MEDICAL HISTORY,Significant for deep venous thrombosis and acid reflux.,PAST SURGICAL HISTORY,Significant for appendectomy, colonoscopy and BAM.,MEDICATIONS,1.  Coumadin.  She stopped her Coumadin five days prior to the procedures.,2.  Lipitor,3.  Effexor.,4.  Klonopin.,ALLERGIES,None.,REVIEW OF SYSTEMS,Negative for dyspnea on exertion, palpitations, chest pain, and phlebitis.,PHYSICAL EXAMINATION,VITAL SIGNS:  Height 5'8"", weight 155 pounds.,FACE:  Examination of the face demonstrates basal cell carcinoma, right and left cheek.  No lesions are noted in the regional lymph node base and no mass is appreciated.,BREAST:  Examination of the breast demonstrates bilateral grade IV capsular contracture.  She has asymmetry in distortion of the breast.  No masses are appreciated in the breast or the axilla.  The implants appear to be subglandular.,CHEST:  Clear to auscultation and percussion.,CARDIOVASCULAR:  Regular rate and rhythm.,EXTREMITIES:  Show full range of motion.  No clubbing, cyanosis or edema.,SKIN:  Significant environmental actinic skin damage.,I recommended excision of basal cell cancers with frozen section control of the margin, closure will require local tissue flaps.  I recommended exchange of the implants with reaugmentation.  No final size is guaranteed or implied.  We will decrease the size of the implants based on the intraoperative findings as the size is not known.  Several options are available.  Sizer implants will be placed to best estimate postoperative size.  Ptosis will be worse following capsulectomy and going with a smaller implant.  She may require a lift in the future.  We have obtained preoperative clearance from the patient's cardiologist, Dr. K.  The patient has been taken off Coumadin for five days and will be placed back on Coumadin the day after the surgery.  The risk of deep venous thrombosis is discussed.  Other risk including bleeding, infection, allergic reaction, pain, scarring, hypertrophic scarring and poor cosmetic resolve, worsening of ptosis, exposure, extrusion, the rupture of the implants, numbness of the nipple-areolar complex, hematoma, need for additional surgery, recurrent capsular contracture and recurrence of the skin cancer was all discussed, which she understands and informed consent is obtained.,PROCEDURE IN DETAIL,After appropriate informed consent was obtained, the patient was placed in the preoperative holding area with **** input.  She was then taken to the major operating room with ABCD Surgery Center, placed in a supine position.  Intravenous antibiotics were given.  TED hose and SCDs were placed.  After the induction of adequate general endotracheal anesthesia, she was prepped and draped in the usual sterile fashion.  Sites for excision and skin cancers were carefully marked with 5 mm margin.  These were injected with 1% lidocaine with epinephrine.,After allowing adequate time for basal constriction hemostasis, excision was performed, full thickness of the skin.  They were tagged at the 12 o'clock position and sent for frozen section.  Hemostasis was achieved using electrocautery.  Once margins were determined to be free of involvement, local tissue flaps were designed for advancement.  Undermining was performed.  Hemostasis was achieved using electrocautery.  Closure was performed under moderate tension with interrupted 5-0 Vicryl.  Skin was closed under loop magnification paying meticulous attention and cosmetic details with 6-0 Prolene.  Attention was then turned to the breast, clothes were changed, gloves were changed, incision was planned and the previous inframammary incision beginning on the right incision was made.  Dissection was carried down to the capsule.  It was extremely calcified.  Dissection of the anterior surface of the capsule was performed.  The implant was subglandular, the capsule was entered, implant was noted to be grossly intact; however, there was free silicone.  Implant was removed and noted to be ruptured.  No marking as to the size of the implant was found.,Capsulectomy was performed leaving a small portion in the axilla in the inframammary fold.  Pocket was modified to medialize the implant by placing 2-0 Prolene laterally in mattress sutures to restrict the pocket.  In identical fashion, capsulectomy was performed on the left.  Implant was noted to be grossly ruptured.  No marking was found for the size of the implant.  The entire content was weighed and found to be 350 grams.  Right side was weighed and noted to be 338 grams, although some silicone was lost in the transfer and most likely was identical 350 grams.  The implants appeared to be double lumen with the saline portion deflated.  Completion of the capsulectomy was performed on the left.",BCCa Excision - Cheek,Hematology - Oncology,
"Bronchoscopy with bronchoalveolar lavage.  Refractory pneumonitis.  A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.","PREOPERATIVE DIAGNOSIS:,  Refractory pneumonitis.,POSTOPERATIVE DIAGNOSIS: , Refractory pneumonitis.,PROCEDURE PERFORMED: , Bronchoscopy with bronchoalveolar lavage.,ANESTHESIA: , 5 mg of Versed.,INDICATIONS: , A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,PROCEDURE: , The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube.  Bronchoscope was advanced.  Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  Relatively few tenacious secretions were noted.  These were lavaged out.  Specimen collected for culture.  No obvious other abnormalities were noted.  The patient tolerated the procedure well without complication.",Bronchoscopy & Bronchoalveolar Lavage,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis"
MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).,"CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.",Acute Intracerebral Hemorrhage,Radiology,
"Patient with hypertension, syncope, and spinal stenosis - for recheck.","SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.",Hypertension - Progress Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,"
"Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.","REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:",Consult - Atrial Fibrillation - 1,Cardiovascular / Pulmonary,
"Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.","CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:",Thrombocytosis Followup,Hematology - Oncology,
Neurologic consultation and follow-up.,"SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.",Neurologic Consultation - 1,Neurology,"neurology, neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,"
3-Dimensional Simulation.  This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.,"3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.  This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects.  With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended.  The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized.  Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived.  Radiographs are taken and these films are approved by the physician.  Appropriate marks are placed on the patient's skin or on the  immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are performed through the targeted area.  The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images.  The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures.  This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features.  Appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised.  If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.",3-Dimensional Simulation,Hematology - Oncology,"hematology - oncology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.,"PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.",Esophagogastroduodenoscopy with Biopsies -2,Gastroenterology,"gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,"
Colonoscopy with random biopsies and culture.,"PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.",Colonoscopy with Biopsy - 4,Gastroenterology,"gastroenterology, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy"
Patient referred for narrow angles and possible associated glaucoma.,"XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear XYZ:,Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma.  I examined Mrs. ABC initially on MM/DD/YYYY.  At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache.  She reports a family history of glaucoma in her mother, but is unsure of the specific kind.  Her past ocular history has been fairly unremarkable.  As you know, she has a history of non-insulin dependent diabetes.  She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me.  She is followed by Dr. X here locally.,Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses.  Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m.  Pupillary reactions, confrontational visual fields, and ocular motility were normal.  The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure.  I deferred the dilated portion of the exam on that day.,We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent.  I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes.  Therefore, I feel she has sustained some optic nerve damage perhaps from intermittent angle closure in the past.,In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs.  Her intraocular pressures have remained stable.  I will continue to monitor her closely.,Thank you very much once again for allowing me to have shared in her care.  If I can provide any additional information or be of further service, do let me know.,Sincerely,,",Ophthalmology - Letter - 3,Ophthalmology,"ophthalmology, intraocular pressures, narrow angles, visual fields, angles, intraocular, pressures, anterior, chambers, gonioscopy, glaucoma, narrow, visual, eye,"
"Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.","CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.",Rotator cuff syndrome - H&P,Orthopedic,
NexGen left total knee replacement.  Degenerative arthritis of left knee.  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.,"PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:,  Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME:  Approximately 66 minutes.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:,  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.  She wishes to proceed with arthroplasty at this time.,PROCEDURE:  ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03.  She was placed on the operating table.  Department of Anesthesia administered a spinal anesthetic.  Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion.  An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh.  A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum.  A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle.  Care was then ensured that the patellar tendon was not violated.  The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line.  Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia.  The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed.  Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation.  The anterior cutting guide was then placed.  Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur.  After this was performed, this was removed and the distal femoral cutting guide was then placed.  The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken.  After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur.  This was placed slightly in lateral position and secured in position with spring tense and head lift tense.  Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately.  The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws.  After this was performed, the guide was removed and all bony fragments were then removed.  Attention was then directed to the tibia.  The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position.  Care was ensured if it is was a varus or valgus and the appropriate.  The femur gauge was then used to provide us appropriate amount of bony resection.  This was then pinned and secured into place.  Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made.  This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained.  Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability.  The trial components were then removed.  The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment.  After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact.  Again the trial components were placed back into position.  Patella button was placed and the tracking was evaluated.  They tracked centrally with no touch technique.  Again, all components were now removed and the knee was then copiously irrigated and suctioned dry.  Once adequately suctioned dry, the tibial portion was cemented and packed into place.  Also excess cement was removed.  The femoral component was then cemented into position.  All excess cement was removed.  A size 12 poly was then inserted in trial to provide compression at cement adhered.  The patella was then cemented and held into place.  All components were held under compression until cement had adequately adhered all excess cement was then removed.  The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice.  The knee was again copiously irrigated and suctioned dry.  One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place.  After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components.  The knee was once again copiously irrigated, and the tourniquet was deflated.  Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained.  A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl.  This was flexed and the repair was found held securely.  At this point, the knee was again copiously irrigated and suctioned dry.  The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples.  Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied.  The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.",Total Knee Replacement - NexGen,Orthopedic,"orthopedic, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella"
Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,"PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.",Lumbar Re-exploration,Neurosurgery,"neurosurgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,"
Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.,"PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.",Carotid Endarterectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy"
Insertion of a #8 Shiley tracheostomy tube.  A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.,"OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,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, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.  The 2nd tracheal ring was identified.  Next, a #11-blade scalpel was used to make a trap door in the trachea.  The endotracheal tube was backed out.  A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit.  We then secured it in place using 0 silk suture.  A sterile dressing was applied.  The patient tolerated the procedure well.",Shiley Tracheostomy Tube Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,"
A 3-year-old abrupt onset of cough and increased work of breathing.,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",Discharge Summary - Respiratory Distress,Pediatrics - Neonatal,
"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.","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:",Bipolar Affective Disorder - Consult,Psychiatry / Psychology,
Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter.,"PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.",Internal Jugular Vein Catheter Insertion,Nephrology,"nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein"
Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,"PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.",TAH & Salpingo-oophorectomy - 1,Obstetrics / Gynecology,"obstetrics / gynecology, tah, salpingo-oophorectomy, total abdominal hysterectomy, abnormal uterine bleeding, endometrial ablatio, ochsner clamps, round ligaments, clamps, ligaments, cuff, salpingo, oophorectomy, hysterectomy, uterine, ablation, tubes, abdominal, anesthesia,"
Problems with dysphagia to solids and had food impacted in the lower esophagus.  Upper endoscopy to evaluate the esophagus.,"HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.",EGD - 1,Gastroenterology,"gastroenterology, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,"
"Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.","REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.",CT Abdomen & Pelvis - 7,Gastroenterology,"gastroenterology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast"
PICC line insertion,"PROCEDURE PERFORMED:,  PICC line insertion.,DESCRIPTION OF PROCEDURE:,  The patient was identified by myself on presentation to the angiography suite.  His right arm was prepped and draped in sterile fashion from the antecubital fossa up.  Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein.  A guidewire was then threaded through the vein and advanced without difficulty.  An introducer was then placed over the guidewire.  We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram.  What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein.  It was very tortuous area.  We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that.  Decision was made at that point then to just do a midline catheter.  The catheter was cut to 20 cm, then we inserted back to the introducer.  The introducer was removed.  The catheter was secured by two #3-0 silk sutures.  Appropriate imaging was then taken.  Sterile dressing was applied.  The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor.  We may make another attempt in the near future using a different approach.,",PICC line insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.,"SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.",Cardiology Progress Note - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep,"
"Plantar flex third metatarsal and talus bunion, right foot.  Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot.  Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.","PREOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,PROCEDURE PERFORMED:,1.  Third metatarsal osteotomy, right foot.,2.  Talus bunionectomy, right foot.,3.  Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal.  In addition, she complains of a painful right talus bunion to the right foot.  She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.  The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart.  She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction.  Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area.  There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head.  A previous cicatrix was noted with slight hypertrophic scarring.  Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length.  Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen.  Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue.  Any small traversing veins were ligated with electrocautery.  Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue.  Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified.  A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues.  Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal.  McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed.  A moderate amount of plantar adhesions were encountered.  The third toe was plantar flex and the third metatarsal was delivered into the wound.  Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw.  The metatarsal head was allowed to float.  The wound was flushed with copious amounts of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained.  Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal.  There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively.  A #10 blade was used to make a 3 cm incision through the skin.  Next, a #15 blade was used to deepen the incision through the subcutaneous tissue.  Next, the medial and lateral aspects were undermined.  The abductor tendon was identified and retracted.  A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone.  The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis.  A reciprocating rasp was used to smooth all bony prominences.  The wound was flushed with copious amount of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues.  #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.  Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head.  A #15 blade was used to make a small linear incision under the third metatarsal head.  The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa.  The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee.  Copious amounts of Webril were placed on all bony prominences.  3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast.  One was able to insert two fingers to the distal and proximal aspects of the _cast.  The capillary refill time to the digits was less than three seconds after cast application.  The patient tolerated the above anesthesia and procedures without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given standard postoperative instructions to rest, ice and elevate her right foot.  She was counseled on smoking cessation.  She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain.  She was given Keflex #30 1 p.o. t.i.d.  She is to follow up with Dr. X on Monday.  She is to be full weightbearing with a cast boot.  She was given emergency contact numbers to call us if problem arises.",Osteotomy & Bunionectomy - 1,Orthopedic,"orthopedic, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy"
Discharge summary of a patient with mood swings and oppositional and defiant behavior.,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.",Psychiatric Discharge Summary - 2,Psychiatry / Psychology,
"Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.","CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.",Immunohistochemical Study,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,"
A 2-month-old female with 1-week history of congestion and fever x2 days.,"CHIEF COMPLAINT:,  A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:,  The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week.  The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions.  The mother states that the cough is at times paroxysmal and associated with posttussive emesis.  The patient has had short respiratory pauses following the coughing events.  The patient's temperature has ranged between 102 and 104.  She has had a decreased oral intake and decreased wet diapers.  The brother is also sick with URI symptoms, and the patient has had no diarrhea.  The mother reports that she has begun to regurgitate after her feedings.  She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET:  ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:  ,The patient delivered at term.  Birth weight was 6 pounds 1 ounce.  Postnatal complications:  Neonatal Jaundice.  The patient remained in the hospital for 3 days.  The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes.  There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal.  The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS:  GENERAL: , The patient has had fever, there have been no chills.  SKIN:  No rashes.  HEENT:  Mild congestion x1 week.  Cough, at times paroxysmal, no cyanosis.  The patient turns red in the face during coughing episodes, posttussive emesis.  CARDIOVASCULAR:  No cyanosis.  GI:  Posttussive emesis, decreased oral intake.  GU:  Decreased urinary output.  ORTHO:  No current issues.  NEUROLOGIC:  No change in mental status.  ENDOCRINE:  There is no history of weight loss.  DEVELOPMENT:  No loss of developmental milestones.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL:  This is a well-appearing infant in no acute distress.,HEENT:  Shows anterior fontanelle to be open and flat.  Pupils are equal and reactive to light with red reflex.  Nares are patent.  Oral mucosa is moist.  Posterior pharynx is clear.  Hard palate is intact.  Normal gingiva.,HEART:  Regular rate and rhythm without murmur.,LUNGS:  A few faint rales.  No retractions.  No stridor.  No wheezing on examination.  Mild tachypnea.,EXTREMITIES:  Warm, good perfusion.  No hip clicks.,NEUROLOGIC:  The patient is alert.  Normal tone throughout.  Deep tendon reflexes are 2+/4.  No clonus.,SKIN:  Normal.,LABORATORY DATA:,  CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes.  Electrolytes were within normal limits.  C-reactive protein 0.3.  Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view.  UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN:  ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress.  The patient is currently stable in the emergency room.  We will admit the patient to the pediatric floor.  We will send out pertussis PCR.  We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria.  The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia.  We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.",Congestion & Fever - 2-month-old,Pediatrics - Neonatal,
Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,"PREOPERATIVE DIAGNOSIS:,  Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1.  Left hip cemented hemiarthroplasty.,2.  Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1.  DePuy Ultima calcar stem, size 3 x 45.,2.  Bipolar head 28 x 43.,3.  Head with +0 neck length.,4.  Distal centralizer and cement restrictor.,5.  SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS:  ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter.  The lesser trochanter was intact.  The fracture site was noted to show abnormal pathological tissue with grayish discoloration.  The quality of the bone was also pathologically abnormal with soft trabecular bone.  The abnormal pathological tissues were sent along with the femoral head to pathology for assessment.  Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture.  She denied any history of fall or trauma.  The presentation was consistent with pathological fracture pending tissue assessment.  Indication, risks, and benefits were discussed.  Treatment options were reviewed.  No guarantees have been made or implied.,PROCEDURE:  ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up.  The left lower extremity was prepped and draped in a standard sterile fashion.  Time-out procedure was called.  Antibiotics were infused.,A standard posterolateral approach was made.  Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus.  This was then incised along the line of the incision.  Hemostasis was achieved.  Charnley retractor was positioned.  The trochanter was intact.  The gluteus medius was well protected with retractor.  The piriformis and minimus junction was identified.  The minimus was also reflected along with the medius.  Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion.  Similarly, L-shaped capsulotomy was performed.  A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair.  Fracture site was exposed.  The femoral neck fracture was noted to be very low-lying basicervical type.  Femoral head was retrieved without any difficulty with the help of a corkscrew.  The head size was measured to be 43 mm.  Bony fragments were removed.  The acetabular socket was thoroughly irrigated.  A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability.  The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration.  This was sent to the pathology.  The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem.  An L-shaped osteotomy was performed in order to accept the calcar prosthesis.  The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter.  There was no calcar superior to the lesser trochanter.  The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis.  Hemostasis was achieved.  Now, the medullary canal was entered with a canal finder.  The fracture site was well exposed.  Satisfactory lateralization was performed.  Attention was for the reaming process.  Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal.  At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted.  Appropriate anteversion was positioned.  The anteversion was marked with a Bovie to identify subsequent anteversion during implantation.  The bony edges were trimmed.  The calcar implant with 45 mm neck length was fit in the host femur very well.  There was no evidence of any subsidence.  At this point, trial reduction was performed using a bipolar trial head with 0 neck length.  The relationship between the central femoral head and the greater trochanter was satisfactory.  The hip was well reduced without any difficulty.  The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory.  The shuck was less than 1 mm.  Leg length was satisfactory in reference to the contralateral leg.  Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation.  Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees.  After verifying the stability and range of motion in all direction, trial components were removed.  The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely.  At this point, 2 batches of SmartSet cement with antibiotics were mixed.  The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected.  Centralizer was positioned.  The cement restrictor was inserted.  Retrograde cementing technique was applied once the canal was dried.  Using cement gun, retrograde cementing was performed.  The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured.  The excess cement was removed with the help of a curette and Freer elevator.  All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head.  Once again, 0 neck length trial bipolar head was inserted over the trunnion.  It was reduced and range of motion and stability was satisfactory.  I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal.  The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation.  There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation.  I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable.  At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced.  Range of motion and stability was as above.  Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis.  This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster.  Satisfactory reinforcement was achieved with the #5 Ethibond.  The wound was thoroughly irrigated.  Hemostasis was achieved.  The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl.  The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures.  Skin was approximated with staples.  Sterile dressings were placed.  Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.",Cemented Hemiarthroplasty & Biopsy,Orthopedic,
"Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.","PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,",Bronchoscopy - 8,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,"
"Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.","ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,",Discharge Summary - Urology & Nephrology,Nephrology,
"Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.  Displace subcapital fracture, left hip.","PREOPERATIVE DIAGNOSIS:,  Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table.  The right lower extremity was protectively padded.  The left leg was propped with multiple blankets.  The hip was then prepped and draped in the usual manner.  A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues.  Hemostasis was achieved utilizing electrocautery.  Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly.  The external rotators were identified after removal of the trochanteric bursa.  Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line.  They were then reflected distally.  The capsule was then opened in a T-fashion utilizing the cutting cautery.  Fraction hematoma exuded from the hip joint.  The cork screw was then impacted into the femoral head and it was removed from the acetabulum.  Bone fragments were removed from the neck and acetabulum.  The acetabulum was then inspected and noted to be free from debris.  The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur.  The T-handle broach was then passed down the canal.  The canal was then sequentially broached up to a medium broach.  The calcar was then plained with the hand plainer.  The trial components were positioned into place.  The medium component fit fairly well with the medium 28 mm femoral head.  Once the trial reduction was performed, the hip was taken through range of motion.  There was physiologic crystalling with longitudinal traction.  There was no tendency towards dislocation with flexion of the hip past 90 degrees.  The trial implants were then removed.  The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry.  The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit.  The implant was then impacted into place.  The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup.  The acetabulum was once again inspected, was free of debris.  The hip was reduced.  It was taken through full range of motion.  There was no tendency for dislocation.  The wound was copiously irrigated with gentamicin solution.  The capsule was then repaired with interrupted #1 Ethibond suture.  External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch.  The wound was once again copiously irrigated with gentamicin solution and suctioned dry.  Gluteus fascia was approximated with interrupted #1 Ethibond.  Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples.  A bulky dressing was applied to the wound.  The patient was then transferred to the hospital bed, an abductor pillow was positioned into place.  Circulatory status was intact to the extremity at completion of the case.",Austin-Moore Bipolar Hemiarthroplasty,Orthopedic,"orthopedic, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,"
Diagnosis of bulbar cerebral palsy and hypotonia.,"Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future.  He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  He has been treated by Dr. X through the pediatric neurology clinic.  He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  She also noted and confirmed that he has significant tonsillar hypertrophy.  The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day.  He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms.  He does have an allergy to penicillin.,I appreciate your input on his care.  If you have any questions regarding, please feel free to call me through my office.  Otherwise, I look forward to hearing back from you regarding his evaluation.",Cerebral Palsy - Letter,Neurology,"neurology, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.","PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.",Heart Catheterization & Ventriculogram,Cardiovascular / Pulmonary,
"Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.  The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.","PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.",Dupuytren Disease Excision,Orthopedic,"orthopedic, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger"
Direct laryngoscopy and bronchoscopy.,"PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.",Direct Laryngoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,"
"Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.","SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.",Atrial Fibrillation - SOAP,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,"
"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.","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.",Abnormal Echocardiogram,Cardiovascular / Pulmonary,
Nephrology office visit for followup of CKD.,"HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,",Nephrology Office Visit - 2,Nephrology,
"Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.","PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.",Anterior Cervical Discectomy & Decompression - 1,Neurosurgery,"neurosurgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy"
Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain.,"PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.",Esophagogastroduodenoscopy - 10,Gastroenterology,"gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,"
"Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.","HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.",Bronchoscopy - Fiberoptic,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE"
Psychiatric Consultation of patient with recurring depression.,"CC: , ""Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago."",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them ""cracking down on me."" The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels ""abandoned."" The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior ""I need to answer for my actions."" The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was ""shy"" and ""not smart enough."" The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went ""different directions."",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is ""irritated."" Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.",Psych Consult - Depression - 1,Psychiatry / Psychology,
"Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.","EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.",Cardiac Catheterization - 11,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft"
"Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.","CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,",Lung Biopsy Pathology Report,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node"
"MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.","CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of ""drop"" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.",MRI L-Spine - Subarachnoid Seeding,Neurology,"neurology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,"
2-month-old female - increased work of breathing.,"CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.",Bronchiolitis - 2-month-old,Cardiovascular / Pulmonary,
Reflex sympathetic dystrophy of both lower extremities.,"Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008.  As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  He was seen by Dr. Y at Orthopedic Associates for review of this.  However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation.  Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain.  He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain.  He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  He has been evaluated by Dr. X for rehab concerns to determine.  He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  If you have any questions regarding his care please feel free to call me at my office.  Otherwise, I look forward to hearing back from you shortly after your evaluation.  Please feel free to call me if it is possible or if you have any questions about anything.",Reflex Sympathetic Dystrophy - Letter,Neurology,"neurology, rsd, reflex sympathetic dystrophy, orthopedic, oxygenationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.",Low-Transverse C-Section - 9,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy, herpes simplex virus, hepatitis c, cephalopelvic disproportion, asynclitism, postpartum, macrosomia, low transverse cervical cesarean section, rectus fascia, cesarean section, intrauterine, transaminases, herpes, uterus, fascia,"
"Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.","TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.",Pars Plana Vitrectomy & Lensectomy,Ophthalmology,
Primary low segment cesarean section.,"PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.",Low -Segment C-Section,Obstetrics / Gynecology,"obstetrics / gynecology, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,"
Lexiscan myoview stress study.  Chest discomfort.  Normal stress/rest cardiac perfusion with no indication of ischemia.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,"LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection.  At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software.  The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94.  Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury.  Subtle nonspecific in III and aVF were seen.  Maximum stress test EKG showed inverted T wave from V4 to V6.  Normal response to Lexiscan.,CONCLUSION:  ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive.  Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1.  Normal stress/rest cardiac perfusion with no indication of ischemia.,2.  Normal LV function and low likelihood of significant epicardial coronary narrowing.,",Mayoview - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,"
"External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.","PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.",Pilon Fracture External Fixation,Orthopedic,"orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,"
"Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.","PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.",Cardiac Allograft Transplant,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery"
"The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.","HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much ""it hurts."",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.",Left Lower Quadrant Pain - ER Visit,Obstetrics / Gynecology,
A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.,"REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA:",Hepatic Encephalopathy,Gastroenterology,
Laparoscopic tubal fulguration.,"A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.",Tubal Fulguration - Laparoscopic,Obstetrics / Gynecology,"obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.   Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.  Open reduction, right both bone forearm fracture with placement of long-arm cast.","PREOPERATIVE DIAGNOSIS:  ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1.  Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2.  Open reduction, right both bone forearm fracture with placement of long-arm cast.,COMPLICATIONS:,  None.,TOURNIQUET: , None.,ESTIMATED BLOOD LOSS:,  25 mL.,ANESTHESIA: , General.,INDICATIONS:  ,The patient suffered injury at which time he fell over a concrete bench.  He landed mostly on the right arm.  He noted some bleeding at the time of the injury and a small puncture wound.  He was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,He was indicated the above-noted procedure.  This procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  They understood these well.  All questions were answered and they signed the consent for procedure as described.,DESCRIPTION OF PROCEDURE:  ,The patient was placed on the operating table and general anesthesia was achieved.  The right forearm was inspected.  There was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half.  There was bleeding in this region.  No gross contamination was seen.  At this point, under fluoroscopic control, I did attempt to see a fracture.  I was unable to do the forearm under the close reduction techniques.  At this point, the right upper extremity was then prepped and draped in the usual sterile manner.  An incision was made through the puncture wound site extending this proximally and distally.  There was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed.  I also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed.  These were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which I communicated through the puncture wound.  Both ends were clearly visualized, and thorough irrigation was performed using total of 6 L of antibiotic solution.  All nonviable gross contaminated tissue was removed.  At this point with the bones in direct visualization, I did reduce the bony ends to anatomic alignment with excellent bony approximation.  Proper alignment of tissue and angulation was confirmed.,At this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously.  The ulna was now also noted to be in anatomic alignment.,At this point, the region was thoroughly irrigated.  Hemostasis confirmed and closure then begun.  The skin was reapproximated using 3-0 nylon suture.  The visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch Nugauze with iodoform.  Sterile dressing applied and a long-arm cast with the forearm in neutral position was applied.  X-ray with fluoroscopic evaluation was performed, which confirmed.  They maintained excellent bony approximation and the anatomic alignment.  The long-arm cast was then completely mature.  No complications were encountered throughout the procedure.  The patient tolerated the procedure well.  The patient was then taken to the recovery room in stable condition.",I&D & Open Reduction - Forearm,Orthopedic,"orthopedic, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,"
Posterior spinal fusion and spinal instrumentation.  Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,"PREOPERATIVE DIAGNOSIS: , Severe scoliosis.,ANESTHESIA: , General.  Lines were placed by Anesthesia to include an A line.,PROCEDURES: ,1.  Posterior spinal fusion from T2-L2.,2.  Posterior spinal instrumentation from T2-L2.,3.  A posterior osteotomy through T7-T8 and T8-T9.  Posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,IMPLANT: , Sofamor Danek (Medtronic) Legacy 5.5 Titanium system.,MONITORING: , SSEPs, and the EPs were available.,INDICATIONS: , The patient is a 12-year-old female, who has had a very dysmorphic scoliosis.  She had undergone a workup with an MRI, which showed no evidence of cord abnormalities.  Therefore, the risks, benefits, and alternatives were discussed with Surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control.  I also discussed ___________ and need for revision surgery.  The mom understood all this and wished to proceed.,PROCEDURE: , The patient was taken to the operating room and underwent general anesthetic.  She then had lines placed, and was then placed in a prone position.  Monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials.  The SSEPs were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning.  It was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet.  She was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the SSEPs.,The patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down.  The dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes.  This occurred from T2-L2.  Fluoroscopy was brought in to verify positions and levels.  Once this was done, and all bleeding was controlled, retractors were then placed.  Attention was then turned towards placing screws first on the left side.  Lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance.  The area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact.  They were then tapped, and then screws were then placed.  This technique was used at L1 and L2, both the right and left.  At T12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position.  Two screws, in the right and left were placed at T12 as well, reduction screws on the left.  The same technique was used for T11, where right and left screws were placed as well as T10 on the left.  At T9, a screw was placed on the left, and this was a reduction screw.  On the left at T8, a screw could not be placed due to the dysmorphic nature of the pedicle.  It was not felt to be intact; therefore, a screw was left out of this.  On the right, a thoracic screw was placed as well as at 7 and 6.  This was the dysmorphic portion of this.  Screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks.  Pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook.  Upgoing pedicle hooks were placed at T3, T4, and T5.  A downgoing laminar hook was placed at the T7 level.  Screws had been placed at T6 and T7 on the right.  An upgoing pedicle hook was also placed at T3 on the right, and then, downgoing laminar hooks were placed at T2.  This was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks.  Once all hooks were in place, spinal osteotomies were performed at T7-T8 and T8-T9.  This was the level of the kyphosis, to bring her back out of her kyphoscoliosis.  First the ligamentum flavum was resected using a large Kerrisons.  Next, the laminotomy was performed, and then a Kerrison was used to remove the ligamentum flavum at the level of the facet.  Once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis.  This was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides.  This was done also between the T8-T9.  Once this was completed, Gelfoam was then placed.  Next, we observed, and measured and contoured.  The rods were then seated on the left, and then a derotation maneuver was performed.  Hooks had come loose, so the rod was removed on the left.  The hooks were then replaced, and the rod was reseated.  Again, it was derotated to give excellent correction.  Hooks were then well seated underneath, and therefore, they were then locked.  A second rod was then chosen on the right, and was measured, contoured, and then seated.  Next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at T7 was then helped to compress T8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely.  Next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction.  On the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out L2.  Once this was done, all screws were tightened.  Fluoroscopy was then brought in to verify L1 was level, and the first ribs were also level, and it gave a nice balanced spine.  Everything was copiously irrigated, ___________.  Next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet.  The patient was then again sedated and brought back under general anesthesia.  Next, a high-speed burr was used for decortication.  After final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 mL of iliac crest aspirate and were placed into the wound.  The open canal areas had been protected with Gelfoam.  Once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 Vicryl, and then the skin was closed with 3-0 Monocryl and Dermabond.  Sterile dressing was applied.  Drains had been placed in the subcutaneous layer x2.  The patient during the case had no changes in the SSEPs, had a normal wake-up test, and had received Ancef and clindamycin during the case.  She was taken from the operating room in good condition.",Spinal Fusion & Instrumentation,Orthopedic,"orthopedic, osteotomy, laminotomy-foraminotomy, sofamor danek, sseps, spinal fusion, transverse processes, pedicle hooks, pedicle, laminotomy, hooks, screws, instrumentation, decompression, scoliosis, sofamor, foraminotomy, spinal"
"The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.","REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",Neuroblastoma - Consult,Pediatrics - Neonatal,
No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,"INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure.  The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia.  He is currently stabilized and improving in strength.  He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program.  He has a few other significant medical problems.,MEDICATIONS:,1.  Toprol-XL 25 mg daily.,2.  Simvastatin 80 mg daily.,3.  Aspirin 81 mg daily.,4.  Synthroid 0.5 mg daily.,5.  Warfarin 1.5 mg daily.,PHYSICAL EXAMINATION: , The patient appears pale and fragile.  He is comfortable at rest.  His resting heart rate is 80.  His resting blood pressure is 112/70.  His conjunctivae are pale.  His lungs have decreased breath sounds throughout and dullness at the bases bilaterally.  Heart exam reveals a distant S1 and S2.  There is a short 2/6 systolic ejection murmur.  The extremities are normal without clubbing, cyanosis or edema.,The resting echocardiogram showed a sinus rhythm at 70 beats per minute.  There is poor R wave progression across the pericardium and Q waves inferiorly.,DESCRIPTION:  ,The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath.  He did not experience chest pain with exercise.  He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate.  His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS.  As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression.  There were no significant ST segment changes with exercise.  There were only rare ventricular premature beats with exercise.,CONCLUSION:,1.  Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,2.  No chest pain with exercise.,3.  No significant ECG changes with exercise.,4.  The patient is considered stable to enter our cardiac rehabilitation program.  I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.",Exercise Stress Test - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial,"
Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.,"CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity.  2) VBG, 1990.  3) A-Fib. 4) HTN.  5) Hypothyroidism.  6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.",Cerebral Angiogram & MRA,Neurology,"neurology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram"
"Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.","REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",Lung Cancer & MI - Hospice Cosult,Cardiovascular / Pulmonary,
"Diagnostic arthroscopy exam under anesthesia, left shoulder.  Debridement of chondral injury, left shoulder.  Debridement, superior glenoid, left shoulder.  Arthrotomy.  Bankart lesion repair.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).","TITLE OF OPERATION:,1.  Diagnostic arthroscopy exam under anesthesia, left shoulder.,2.  Debridement of chondral injury, left shoulder.,3.  Debridement, superior glenoid, left shoulder.,4.  Arthrotomy.,5.  Bankart lesion repair.,6.  Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder.  Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications.  The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1.  Anterior instability, left shoulder.,2.  Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3.  Type 1 superior labrum anterior and posterior lesion, left shoulder.,4.  Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5.  Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically.  She had full range of motion with no joint adhesions.  She had equal range of motion bilaterally.  She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders.  This was the same when the arm was in neutral or in external rotation.  The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated.  Peroneal nerve was well protected.  All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the start of the procedure to decrease the risk of infection.  The arm was placed in a arm holder with 10 pounds of traction.  A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline.  A small incision was made after infiltrating the skin with Marcaine and epinephrine.  The scope was introduced into the shoulder with no difficulty.  It was then examined systematically.  The patient did have diffuse synovitis throughout her shoulder.  Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head.  She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury.  This had some portions of fibrillated and loose cartilage, hanging from the edges.  These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal.  The supraspinatus, infraspinatus tendons were normal.  The inferior pouch was normal with no capsular tearing and no HAGL lesions.  The posteroinferior labrum was normal as well as the posterosuperior labrum.  There was some fraying in the posterosuperior labrum, which was later debrided.  It was found essentially to be a type 1 lesion anteriorly and superiorly.  The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole.  The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum.  The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position.  The biceps anchor itself was later probed and found to be stable and normal.  The subscapularis tendon was normal.  The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid.  There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened.  The patient was missing about 10 to 15% of her anteroinferior glenoid rim.  The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion.  There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees.  The arm abducted and externally rotated.  There was contact to the rotator cuff with posterosuperior labrum.  This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation.  It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees.  The patient did have a positive relocation maneuver.  The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder.  Anterior portal was created with Wissinger rod.  A blue cannula was inserted into the shoulder without difficulty.  Shaver was introduced in the labrum.  Also the area of chondromalacia as mentioned above was debrided.  The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion.  The instruments were then removed along with excess fluid.  The posterior portals were closed with single 4-0 nylon suture.  The anterior portal was left open.  The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line.  Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case.  The interval was developed down the clavipectoral fascia.  The conjoined tendon was retracted medially and the deltoid laterally.  The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers.  The capsule could easily be detached from the muscle, and the interval developed very easily.  A retractor was placed inferiorly to protect the axillary nerve.  Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position.  The labrum was identified and found to be attached all the way down to 6 o'clock position.  The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture.  The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening.  This was debrided with the soft tissue.  Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck.  These were absorbable anchors with nonabsorbable sutures.  They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique.  This brought the capsule right up to the edge of the glenoid rim.  With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization.  The capsule did come right up into the joint as expected with this type of repair.  The superior flap was then closed, the inferior flap over the superior anchor.  The interval between two flaps was closed with multiple number 2 Ti-Cron sutures.  Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached.  The arm abducted 90 degrees.  There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation.  The subscapularis split was closed with interrupted 0 Vicryl sutures.  The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures.  The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures.  The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the recovery room in stable and satisfactory condition.","Arthroscopy, Arthrotomy, Bankart lesion repair",Orthopedic,"orthopedic, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy,"
"Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.","PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.",Epidural Hematoma Evacuation,Neurosurgery,"neurosurgery, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia,"
Patient returns for his first followup after shunt surgery.,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",First Followup - Shunt Surgery,Neurology,
CT Abdomen & Pelvis W&WO Contrast,"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.",CT Abdomen & Pelvis,Gastroenterology,"gastroenterology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,"
"Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.","DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.",Breast Radiation Therapy Followup,Hematology - Oncology,"hematology - oncology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,"
The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.,"PROCEDURE IN DETAIL:  ,While in the holding area, the patient received a peripheral IV from the nursing staff.  In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain.  Approximately 3 mL were administered.  The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  Blunt dissection was carried out in the superotemporal quadrant.  Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  This flap was cut forward to clear cornea using a crescent blade.  The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.  The tube was then cut to an appropriate length to enter the anterior chamber.  The anterior chamber was then entered after a paracentesis wound had been made temporally.  A trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  The tube was sutured in place with a multi-wrapped 8-0 nylon suture.  The scleral flap was then sutured in place with two 10-0 nylon sutures.  The knots were trimmed, rotated and buried.  A scleral patch was then placed of an appropriate size over the two.  It was sutured in place with interrupted 8-0 nylon sutures.  The knots were trimmed.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle.  The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft.  A good flow was established with irrigation into the anterior chamber.  Homatropine, Econopred, and Vigamox drops were placed into the eye.  A patch and shield were placed over the eye after removing the draping and the speculum.  The patient tolerated the procedure well.  He was taken to the recovery in good condition.  He will be seen in followup in the office tomorrow.",Ahmed Shunt Placement,Ophthalmology,"ophthalmology, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.","ADMISSION DIAGNOSIS:,  End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:,  Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY:  ,1.  Diabetes mellitus diagnosed 12 years ago.,2.  Hypertension.,3.  Coronary artery disease with a myocardial infarct in September of 2006.,4.  End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY:  ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:,  Hypertension.,PHYSICAL EXAMINATION:  ,GENERAL:  The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS:  Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182.  Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295.  Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit.  Initially, the patient had a decrease in hematocrit from 30 to 25.  The patient's hematocrit stabilized at 25.  During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  The patient was making excellent urine throughout his stay.  The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor.  The patient was advanced in diet appropriately.  The patient was started on Prograf by postoperative day #2.  Initial Prograf levels came back high at 18.  The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  During the patient's stay, the patient received four total doses of Thymoglobulin.  Today, he will complete his final dose of Thymoglobulin prior to being discharged.  In addition, today, the patient has an elevated blood pressure of 198/96.  The patient is being given an extra dose of metoprolol for this blood pressure.  In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  He is discharged on a low-potassium diet with activity as tolerated.  He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked.  The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.",ESRD - Discharge Summary,Nephrology,
Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,"PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.",Endotracheal Intubation - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE"
Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized.,"PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.",Knee Arthroplasty - Bilateral,Orthopedic,"orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,"
"Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.","PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.",Phenol Neurolysis & Botulinum Toxin Injection - 3,Neurosurgery,"neurosurgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin"
Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope.,"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.",Anterior Cervical Discectomy & Fusion - 6,Orthopedic,"orthopedic, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,"
"Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.","TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.",Laminectomy & Discectomy & Facetectomy,Neurosurgery,"neurosurgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,"
Ultrasound OB - followup for fetal growth.,"REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.",Ultrasound OB,Obstetrics / Gynecology,"obstetrics / gynecology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,"
"Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.","PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.",Colonoscopy - 14,Gastroenterology,"gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid"
"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.","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.",Thromboendarterectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE"
Right nodular malignant mesothelioma.,"PREOPERATIVE DIAGNOSIS:,  Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1.  Right thoracotomy.,2.  Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:,  Stable, extubated, to PACU.,PROCEDURE IN DETAIL:,  Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm.  He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma.  Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm.  He was explained the risks, benefits, and alternatives to this procedure.  He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed.  He was put in a supine position where SCDs and Foley catheter were placed.  He was put under general endotracheal anesthesia with a double-lumen endotracheal tube.  He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered.  Upon entering the chest, the chest wall retractor was inserted and the cavity inspected.  It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm.  He also had some marked lymphadenopathy.  With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection.  Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly.  We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe.  The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties.  Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment.  This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk.  This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe.  This was also ligated in continuity and actually doubly ligated.  Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein.  The superior pulmonary vein was visualized as well.  The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie.  Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures.  The bronchial anatomy was defined.  Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe.  A TA-30 4.8 stapler was then closed.  The lung insufflated.  The right middle lobe and right upper lobe were noted to inflate well.  The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm.  There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin.  Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved.  It seemed that it would be a mucoid shallow portion.  The Bovie was set to high cautery.  The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver.  It did leave quite a shallow defect in the liver.  Hemostasis was achieved with Bovie cautery and gentle pressure.  The specimen was then taken off the table and sent to Pathology for permanent.  The area was inspected for hemostasis.  A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension.  A single 32 straight chest tube was also placed.  The lung was seen to expand.  We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe.  Hemostasis was observed at the end of the case.  The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump.  The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs.  The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin.  The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.",Mesothelioma - Thoracotomy & Lobectomy,Hematology - Oncology,"hematology - oncology, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy,"
Bilateral temporal artery biopsy.  Rule out temporal arteritis.,"PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.",Temporal Artery Biopsy,Neurology,"neurology, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis"
CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.,"CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting ""3 hours"" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed ""Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.",Arachnoid Cyst,Neurology,"neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid"
Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.,"INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.",Pulmonary Hypertension - Pediatric Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary"
"Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.","PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.",Neck Dissection,ENT - Otolaryngology,"ent - otolaryngology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer"
CT chest with contrast.,"EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  There are linear fibrotic or atelectatic changes associated with this.  Recommend followup to ensure resolution.  There is left apical scarring.  There is no pleural effusion or pneumothorax.  There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid.  Cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  The heart is not enlarged.  There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation.  Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.",CT Chest - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,"
Dysphagia and hematemesis while vomiting.  Diffuse esophageal dilatation/hematemesis,"CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.",Dysphagia & Hematemesis,Gastroenterology,
Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft.,"PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.",Laminectomy & Foraminotomy & Cervical Fusion,Neurosurgery,
"Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.","PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.",Laryngoscopy & Vocal Cord Biopsy,ENT - Otolaryngology,"ent - otolaryngology, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia"
"Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.","PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.","Heart Catheterization, Ventriculography, & Angiography - 6",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,"
This is a 95.5-hour continuous video EEG monitoring study.,"TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  The patient was recorded digitally using the 10-20 system of electrode placement.  Additional temporal electrodes and single channels of EOG and EKG were also recorded.  The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated.  Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION:  ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:,  There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event.  The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  At 1:38 p.m., the patient was instructed to begin hyperventilation.  Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  When asked what had just occurred, she replied that she was asleep and did not remember any event.  When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event.  Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:,  The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation.  No epileptiform activity is present.  One clinical event was induced with hyperventilation and photic stimulation.  The clinical features of this event are described in the technical summary above.  There was no epileptiform activity associated with this event.  This finding is consistent with a non-epileptic pseudoseizure.",EEG Monitoring Study,Neurology,"neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring"
"CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.","EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.","CT Head, Facial Bones, Cervical Spine",Neurology,"neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical"
"Psychiatric evaluation for ADHD, combined type.","IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr.  Circumstances leading to this admission:  In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h.  Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper.  ABCD is also complaining of headaches when he takes the medication.  Mother reports that on the weekends he is off the medication.  She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, ""It's an accident.""  She sees him as impulsive on the weekends, but is not sure if this just isn't ""all boy."",Mother reports ABCD has been on medication since kindergarten.  Currently, the teachers say he is able to pay attention and he is well behaved in school.  Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct.  He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep:  As stated before, he is having much difficulty on a consistent basis falling asleep.  It is 12:00 to 1:00 a.m. before he falls to sleep.  When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty.  On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite:  He will eat breakfast and supper, but not much lunch, if any at all.  He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control:  Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior.  The only exception to this is he gets in occasional fights with his sisters.  ABCD denies visual or auditory hallucinations or racing thoughts.  He reports his thoughts are sometimes bad because he says sometimes he thinks of the ""S"" word.,Energy:  Mother reports a lot of energy.,Pain:  ABCD denies any pain in his body.,Suicidal or homicidal thoughts:  He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06.  He has received outpatient therapy from XYZ, LCSW.  He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar.  She reports she has significant moodiness episodes and believes in the past she has had a manic episode.  She is currently not on medication.  She does not know of anyone else in her family, with the exception of she said her father's behavior was ""weird.""  Biological father's side of the family, mother reports father was very impulsive.  He had anger issues.  He had drug and alcohol issues.  He was in jail for three years for risky behavior.  There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years.  They divorced when ABCD was 2-1/2 years of age.  Currently, father has been deported back to Mexico.  He last saw ABCD in March 2006 for one day when they went down to AAAA.  He does call on special holidays and his birthday.  Contact is brief, but so far has been consistent.  Mother is currently seeing R, a significant other, and has been seeing him for the last seven months.  ABCD had a good relationship with R.  ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as ""all wisdom."",PREGNANCY:,  Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero.  She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:,  Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:,  Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:,  Mother reports ABCD was a very cuddly infant and could sleep well.  As a toddler, he was all over the place, climbing and always busy.  Elementary school:  In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen.  ABCD has no history of fire setting or abuse to animals.  He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:,  Noncontributory.,MEDICAL STATUS AND HISTORY:,  ABCD has no known drug allergies.  He has no history of heart murmur, heart defect of other heart problems.  No history of asthma, seizures or head injuries.  He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:,  When I asked ABCD whether he likes school, he stated, ""No.""  His grades are okay, per mother.  He does have an IEP for the ADHD, but she does not believe he has a learning disability.  Behavior problems:  He currently is not having any behavior problems in the school.  He reports he does not get along with his teachers because they tell him what to do.  Strengths:  He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:,  He reports he has best friends.  He named two, D and B, and he does have a friend that is a girl named Kim.  When asked if church or God were important to him, he stated, ""God is.""  He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:,  In the home, he has chores of taking out the trash.,LEGAL:,  He has not been involved in the legal system.,SUPPORT SYSTEMS:,  When asked if he feels safe in his home, he stated, ""Yes.""  When asked who he talks to if he is hurt or upset, he stated, ""Mom.""  (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:,  He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:,  This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions.  ABCD kept himself occupied throughout and was very well behaved throughout the session.  He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes.  Distractibility and attention:  He, at times, was very mildly distracted, but otherwise did not appear hyperactive.  His judgment was adequate.  When asked what he would do if there was a fire in his house, he said, ""Get out!""  Insight was poor to adequate.  Fund of information was good.  When asked who the president was, he said, ""George Washington."" Intelligence is probably average to above average.  Speech was normal.  He had some difficulty with abstract thinking.  He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle.  On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly.  When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly.  Appearance was casual.  Hygiene was good.  Attitude was cooperative.  Speech was normal.  Psychomotor was between normal and slightly hyperactive.  Orientation was x2.  Attention/concentration was intact.  Memory was intact at times and then had some memory recall problems with three words.  Mood was euthymic.  Affect was bright.  He has no suicidal or homicidal/violence risks.  Perceptions were normal.  Thought process logical.  Thought content normal.  Disassociation none.  Sleep:  He is having some insomnia.  Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:,  He has a strong support system in his mother, grandmother, and mother's significant other, Richard.  He has good health.  He has shown gain from past treatment.  He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.",Psychiatric Evaluation - 3,Psychiatry / Psychology,
Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,"PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.",Neuroplasty,Neurosurgery,"neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,"
Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.,"SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.",Cardiology Progress Note - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep,"
"Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.","CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:",Endometrial Cancer Followup,Hematology - Oncology,"hematology - oncology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,"
"Placement of Scott cannula, right lateral ventricle","PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.",Scott Cannula,Neurosurgery,"neurosurgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
CT Brain: Subarachnoid hemorrhage.,"CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.",CT Brain - SAH,Neurology,"neurology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness,"
Left shoulder injury.   A 41-year-old male presenting for initial evaluation of his left shoulder.,"CHIEF COMPLAINT:  ,",Shoulder Contusion,Orthopedic,"orthopedic, shoulder, injury, two views, shoulder contusion,"
"Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.","ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",Multiple Medical Problems - Discharge Summary,Gastroenterology,
"Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.","CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a ""high grade stenosis"" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled ""world"" backward, as ""dlow."",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.",CT Scan of Brain with Contrast,Neurology,"neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal,"
"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.","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",Thoracotomy & Esophageal Exploration,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,"
"Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.","IMPRESSION:,  Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.  Clinical correlation is suggested.",Electroencephalogram - 3,Neurology,"neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.","DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.",CVA - Discharge Summary,Neurology,"neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident"
"Removal of painful hardware, first left metatarsal.  Excision of nonunion, first left metatarsal.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.","TITLE OF OPERATION:,1.  Removal of painful hardware, first left metatarsal.,2.  Excision of nonunion, first left metatarsal.,3.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,ANESTHESIA:,  General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:,  2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was then inflated.  Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon.  The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the periosteum of the first left metatarsal.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft.  Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact.  The screws were sent to pathology for examination.  The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification.  The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding.  The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy.  Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished.  The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft.  Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent.  The area was flushed copiously flushed with saline.  The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material.  All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time.  The left ankle tourniquet was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels.  The patient was given specific instructions and education on how to continue caring for his left foot surgery.  The patient was also given pain medications, instructions on how to control his postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.",Hardware Removal - Metatarsal,Orthopedic,"orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws,"
"C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.","PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.",Anterior Cervical Discectomy - 4,Orthopedic,"orthopedic, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,"
Left hip fracture.  The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,"REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  History was obtained from the patient.  As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  She has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  She was seen by her primary care physician and was scheduled to go for MRI yesterday.  However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  Since then, she was unable to ambulate.  The patient called paramedics and was brought to the emergency room.  She denied any history of fall.  She reported that she stepped the wrong way causing the pain to become worse.  She is complaining of severe pain in her lower extremity and back pain.  Denies any tingling or numbness.  Denies any neurological symptoms.  Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture.  Orthopedic consultation was called for further evaluation and management.  On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY:  ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use.  She is divorced with 2 children.  She lives with her son.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL:  Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  Tenderness to palpation is present.  Leg rolling is positive for severe pain in the left proximal hip.  Further examination of the spine is incomplete secondary to severe leg pain.  She is unable to perform a straight leg raising.  EHL/EDL 5/5.  2+ pulses are present distally.  Calf is soft and nontender.  Homans sign is negative.  Sensation to light touch is intact.,IMAGING:,  AP view of the hip is reviewed.  Only 1 limited view is obtained.  This is a poor quality x-ray with a lot of soft tissue shadow.  This x-ray is significant for basicervical-type femoral neck fracture.  Lesser trochanter is intact.  This is a high intertrochanteric fracture/basicervical.  There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:,  Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient.  Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee.  She denies any pain elsewhere.  She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  She understands above and is willing to undergo further procedure.  The goal and the functional outcome have been explained.  Further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient.  I will continue to follow up.",Hip Fracture - ER Consult,Orthopedic,"orthopedic, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma,"
Laparoscopic cholecystectomy.,"PROCEDURE:,:  After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced.  The patient was then prepped and draped in the usual sterile fashion.  An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline.  The fascia was elevated between two Ochsner clamps and then incised.  A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges.  The 11-mm port without the trocar engaged was then placed into the abdomen.  A pneumoperitoneum was established.  After an adequate pneumoperitoneum had been established, the laparoscope was inserted.  Three additional ports were placed all under direct vision.  An 11-mm port was placed in the epigastric area.  Two 5-mm ports were placed in the right upper quadrant.  The patient was placed in reverse Trendelenburg position and slightly rotated to the left.  The fundus of the gallbladder was retracted superiorly and laterally.  The infundibulum was retracted inferiorly and laterally.  Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder.  The triangle of Calot was carefully opened up.  The cystic duct was identified heading up into the base of the gallbladder.  The cystic artery was also identified within the triangle of Calot.  After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder.  The cystic artery was clipped twice proximally and once distally.  Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided.  An intraoperative cholangiogram was obtained.  This revealed good flow through the cystic duct and into the common bile duct.  There was good flow into the duodenum without any filling defects.  The hepatic radicals were clearly visualized.  The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct.  The cystic duct was then divided using scissors.  The gallbladder was then removed up away from the liver bed using electrocautery.  The gallbladder was easily removed through the epigastric port site.  The liver bed was then irrigated and suctioned.  All dissection areas were inspected.  They were hemostatic.  There was not any bile leakage.  All clips were in place.  The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry.  All ports were then removed under direct vision.  The abdominal cavity was allowed to deflate.  The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl.  The fascia at the umbilical port was closed by tying the previously placed stitch.  All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites.  The patient tolerated the procedure well.  The patient is currently being aroused from general endotracheal anesthesia.  I was present during the entire case.",Laparoscopic Cholecystectomy - 1,Gastroenterology,"gastroenterology, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic artery, triangle, port, duct, cysticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Discharge summary of a patient presenting with a large mass aborted through the cervix.,"PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.",Mullerian Adenosarcoma,Hematology - Oncology,"hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma"
Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.,"CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.",Iliopsoas Hematoma - 2,Neurology,"neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,"
Pelvic Pain and vaginal discharge,"CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.",OB/GYN Consultation - 5,Obstetrics / Gynecology,
Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture.  Closed reduction and screw fixation of right femoral neck fracture.  Retrograde femoral nail using a striker T2 retrograde nail.  Irrigation and debridement of knee and elbow abrasions.,"TITLE OF OPERATION:,1.  Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2.  Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  Irrigation and debridement of right knee.,5.  Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,POSTOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT:  ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:,  None.,PLAN:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:,  The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  The risks of surgery were discussed in detail and the consents were signed.  The operative site was marked.  The patient was taken to the operating room where she was given preoperative clindamycin.  The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed.  Attention was turned to the right ankle first.  The large medical laceration was extended and the tissues were debrided.  All dirty of the all injured bone, muscle, and tissues were debrided.  Wound was then copiously irrigated with 8 liters of normal saline.  At this point, the medial malleolus fracture was identified and was reduced.  This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus.  Incision was made over the distal fibula.  It was carried down sharply through the skin in the subcutaneous issues.  Care was taken to preserve the superficial peroneal nerve.  The fracture was identified, and there was noted to be very comminuted distal fibula fracture.  The fracture was reduced and confirmed with fluoroscopy.  A 7 hole Synthes 3.5 mm locking plate was placed.  This was placed in a bridging fashion with three screws above and three screws below the fracture.  Appropriate reduction was confirmed under fluoroscopy.  A cotton test was performed, and the ankle did not open up.  Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded.  All prominences were padded.  The right leg was then prepped and draped in usual sterile fashion.  A 2-cm incision was made just distal to the greater trochanter.  This was carried down sharply through the skin to the fascia.  The femur was identified.  The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position.  The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  A reduction of the fracture was performed prior to placing all the guide wires.  A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated.  The necrotic and dead tissue was removed.  The abrasions did not appear to enter the joints.  They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline.  They were carried down sharply to the skin and the retinacular issues to the joint.  The intercondylar notch was identified.  A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy.  The opening reamer was used following the bolted guide wire was then passed.  The femur was then sequentially reamed using the flexible reamers.  A T2 retrograde nail 10 x 340 was then passed.  Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle.  The wounds were dressed with Xeroform 4 x 4 x 4s and IO band.  The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.","ORIF, Closed Reduction, Screw Fixation, Etc.",Orthopedic,
A 3-year-old abrupt onset of cough and increased work of breathing.,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",Discharge Summary - Respiratory Distress,Pediatrics - Neonatal,
"Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.","PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.",Exploratory Laparotomy & Colon Resection,Gastroenterology,"gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula"
"Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.","CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,",Lymphoblastic Leukemia - Consult,Hematology - Oncology,
Right subclavian triple lumen central line placement,"PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:,  Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION:  ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT:  ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE:  ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.",Central Line Placement,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,"
"Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.","REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1.  Selective coronary angiography.,2.  Left heart catheterization with hemodynamics.,3.  LV gram with power injection.,4.  Right femoral artery angiogram.,5.  Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits.  The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation.  The patient was draped and dressed in the usual sterile fashion.  The right groin area infiltrated with lidocaine solution.  Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch.  The wire was removed.  Catheter was engaged into the left main.  Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed.  Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained.  The cath disengaged and exchanged over J-wire into a pigtail catheter.  Pigtail catheter across the aortic valve.  Hemodynamics obtained.  LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma.  The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS:  ,The aortic pressure was 117/61 with a mean pressure of 83.  The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg.  The pullback across the aortic valve reveals zero gradient.,ANATOMY:  ,The left main showed minimal calcification as well as the proximal LAD.  No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD.  The LAD gave off two early diagonal branches.  The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA.  The left circumflex was large and patent, 6.0 mm in diameter.  All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%.  No mitral regurgitation identified.,IMPRESSION:,1.  Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  Nondominant right, which is free of atheromatous plaque.,3.  Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4.  Normal left ventricular function.,5.  Evaluation for noncardiac chest pain would be recommended.",Coronary Angiography,Cardiovascular / Pulmonary,
"Chronic cholecystitis, cholelithiasis, and liver cyst.  Laparoscopic cholecystectomy and excision of liver cyst.  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.","PREOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,3.  Liver cyst.,PROCEDURES PERFORMED:,1.  Laparoscopic cholecystectomy.,2.  Excision of liver cyst.,ANESTHESIA:  ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1.  Gallbladder.,2.  Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:,  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  Additionally, there was a notable liver cyst.  The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy.  The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  She had had multiple attacks in the past of these complaints.  She was discovered to have had right upper quadrant pain on examination.  Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE:  ,The patient was brought to the operative suite and placed in the supine position.  The patient received preoperative antibiotics with Kefzol.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient did undergo general endotracheal anesthesia.  Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation.  The abdomen was insufflated to 15 mmHg.  After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  Decision to proceed with laparoscopic cystectomy was decided.  A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  All ports were inserted with bladed 5 mm trocar then under direct visualization.  After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  Adhesions adjacent were taken down with a Maryland dissector.  Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  This helped to better delineate the cystic duct as well as the cystic artery.  Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  Utilizing endoscissors, the cystic duct and cystic artery were ligated.  Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  Electrocautery was used to stop any bleeding encountered along the way.  The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  No evidence of stones were visualized.  Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port.  This was sent off as an specimen, a gallstone was identified within the gallbladder.  Next, utilizing copious amounts of irrigation, the abdomen was irrigated.  A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  This was also taken and sent off as specimen.  The abdomen was then copiously irrigated until clear irrigation was identified.  All laparoscopic ports were removed under direct visualization.  The abdomen was de-insufflated.  Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  All incisions were then closed with #4-0 undyed Vicryl.  Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  The areas were cleaned and dried.  Steri-Strips were placed.  On the incisions, sterile dressing was applied.  The patient tolerated the procedure well.  She was extubated following procedure.  She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.",Laparoscopic Cholecystectomy & Liver Cyst Excision,Gastroenterology,"gastroenterology, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic,"
"New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.","REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.",Hand Pain - Consult,Orthopedic,"orthopedic, hand pain, pain, hand, metacarpals"
"Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.","PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.",YAG Laser Capsulotomy,Ophthalmology,"ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia"
A sample note on otitis media.,"OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other.  The ear infection itself is not contagious but the respiratory infection preceding it is transmittable.  Otitis media is most often seen in infants and young children.  There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture.  Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,*  Irritability.,*  Ear pain, fullness, hearing loss.,*  Infants may pull on ear.,*  Fever.,*  Vomiting.,*  Discharge from ear.,*  Diarrhea.,TREATMENT:,*  Diagnosis is by physical exam and otoscopic exam.  Sometimes fluid from the ear is cultured.,*  Pain relievers, like acetaminophen (Tylenol).  Infant pain relievers are available.,*  Decongestant to relieve symptoms of upper respiratory tract infection.,*  Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin.  Finish ALL antibiotics as prescribed.  Do not stop the medication even if symptoms subside.,*  Avoid swimming until infection goes away.,*  Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,*  Surgery to remove adenoids if they are enlarged.,*  Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.",Otitis Media,ENT - Otolaryngology,"ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,"
Selective coronary angiography.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.  Abdominal aortography.,"NAME OF PROCEDURE,1.  Selective coronary angiography.,2.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3.  Abdominal aortography.,INDICATIONS:  ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  Thallium scan has been negative.  He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE:  ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg.  Received additional Versed and fentanyl during the procedure.  Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed.  Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  This revealed a very high-grade lesion at the proximal right coronary artery.  This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  A 6-French sheath and a right Judkins guide was placed.  The patient was started on bivalarudin.  A BMW wire was easily placed across the lesion and into the distal right coronary artery.  A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres.  The intermediate result was improved with TIMI-3 flow to the terminus of the vessel.  Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres.  This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres.  Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  The guiding catheter was withdrawn over wire and a pigtail was placed.  This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  The catheter was removed.  The bivalarudin was stopped at the termination of procedure.  A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein.  This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure.  Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel.  This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch.  It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex.  The ramus intermedius is free of disease.  The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment.  This measures 25% to 30% at its worst point.  The circumflex is a large caliber vessel.  There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation.  This may represent a small retrograde dissection as well.  There was some dye hang up in the wall.,IMPRESSION,1.  Successful stenting of subtotal stenosis of the proximal coronary artery.,2.  Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3.  Left to right collateral filling noted prior to coronary intervention.,4.  Small area of eccentric aneurysm formation in the abdominal aorta.",Coronary Angiography & Abdominal Aortography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,"
"Echocardiogram for aortic stenosis.  Transthoracic echocardiogram was performed of adequate technical quality.  Concentric hypertrophy of the left ventricle with normal function.  Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm","EXAM:,  Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality.  Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function.  Ejection fraction is 60% without any obvious wall motion abnormality.  Left atrium and right side chambers are of normal size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification.  Valvular leaflet excursion is adequate.  Aortic valve reveals annular calcification.  Fibrocalcific valve leaflets with decreased excursion.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation.  Estimated pulmonary pressure of 48.  Systolic consistent with mild-to-moderate pulmonary hypertension.  Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.",Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,"
"Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.   CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.","CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE:  ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS:  ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable.  No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.",CT Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue,"
"Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy.  Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.","PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.",D&C & Laparoscopy - 2,Obstetrics / Gynecology,
Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,"REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:,  This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  Since then, she has generally done well.  She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well.  Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  She denies any rest or exertional chest discomfort.  Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  Later on she was nauseous, but she did not have any vomiting.  She denied any diarrhea.  No history of fever or chills.  Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids.  Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  The patient was admitted however for further workup and treatment.  At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  She has not been fed any food, however.  The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  The patient has had left nephrectomy and splenectomy, which has been described.  A 1.5-mm solid mass is described to be in the lower pole of the kidney.  The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:,  She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that.  She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  She was described to have had a hemorrhagic cyst of the right kidney.  She has mild arthritis for the last 10 or 15 years.  She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  She has a history of diverticulosis as mentioned.  No history of TIA or CVA.  She has one kidney.  She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  She describes this to be a clot on left lung.  I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow.  She lives alone.  She does have three daughters, two of them live in Georgia and one lives in Tennessee.  She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  She never drank any alcohol.  She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:,  Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:,  Appetite is good.  She sleeps good at night.  She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit.  Moderate obesity is present.,CARDIAC:  Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS:  Slightly decreased air entry at both bases.  No rales or rhonchi heard.,CARDIOVASCULAR:  PMI in the left fifth intercostal space in the midclavicular line.  Regular heart rhythm.  S1 and S2 normal.  S4 is present.  No S3 heard.  Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN:  Soft, obese, no tenderness, no masses felt.  Bowel sounds are present.,EXTREMITIES:  Bilateral trace edema.  The extremities are heavy.  There is no pitting at this stage.  No clubbing or cyanosis.  Distal pulses are fair.,CENTRAL NERVOUS SYSTEM:  Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  This is overall unchanged compared to previous electrocardiogram, which also has the same present.  Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  AST and ALT are normal.  Albumin is 4.1.  Lipase and amylase are normal.  INR is 0.92.  Urinalysis is relatively unremarkable except for trace protein.  Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  No infiltrates seen.  Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  Volvulus or adhesions have been considered.  Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1.  Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  Possible small old myocardial infarction.,3.  Hypertension with hypertensive cardiovascular disease.,4.  Non-insulin-dependent diabetes mellitus.,5.  Moderate obesity.,6.  Hyperlipidemia.,7.  Chronic non-pitting leg edema.,8.  Arthritis.,9.  GERD and positive history of peptic ulcer disease.,CONCLUSION:,1.  Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  Lower left quadrant pain, which could be due to diverticulosis.,4.  Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1.  At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.",Cardiac Consultation - 5,Cardiovascular / Pulmonary,
The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.,"HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  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:",Neuro Consult - Leg Weakness,Neurology,
"Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.","PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.",Lumbar Puncture - 2,Neurosurgery,"neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf"
2-D Echocardiogram,"2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.",2-D Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",MRI T-L Spine - Schistosomiasis,Radiology,
"Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.","PREOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,OPERATIONS,1.  Right common carotid endarterectomy.,2.  Right internal carotid endarterectomy.,3.  Right external carotid endarterectomy.,4.  Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:,  General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the right neck was prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors.  The common, internal and external carotid arteries were identified.  The facial vein was ligated with #3-0 silk.  The hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  After dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  Next, an umbilical tape was passed around the common carotid artery.  A #0 silk suture was passed around the internal and external carotid arteries.  The hypoglossal nerve was identified and preserved.  An appropriate sized Argyle shunt was chosen.  A Hemashield patch was cut to the appropriate size.  Next, vascular clamps were placed on the external carotid artery.  DeBakey pickups were used to control the internal carotid artery and common carotid artery.  A #11-blade scalpel was used to make an incision on the common carotid artery.  The arteriotomy was lengthened onto the internal carotid artery.  Next, the Argyle shunt was placed.  It was secured in place.  Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  An inversion technique was used on the external carotid artery.  The artery was irrigated and free debris was removed.  Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion.  Prior to completion of our anastomosis, we removed our shunt.  We completed the anastomosis.  Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  There was no evidence of bleeding.  Full-dose protamine was given.  The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion.  A sterile dressing was applied.",Carotid Endarterectomy - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy"
"This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.","HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments.  He was last seen in this clinic on 05/29/2007 by Dr. X.  This is the first time that I have met the patient.  The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication.  He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year.  He had a baseline creatinine during that time of between 3.2 to 3.3.  When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen.  Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic.  He is currently on three-drug antiretroviral therapy.  His last CD4 count in 03/2008 was 350.  He has had no HIV complications since he was last seen in our clinic.  The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year.  The patient has an AV fistula that was placed in late 2006.  The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9.  These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation.  The only complaint that the patient has at this time is some difficulty sleeping.  He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping.  He says that he has trouble getting to sleep.  The Ambien will allow him to sleep for about two hours, and then he is awake again.  He is tired during the day, but is not taking any daytime naps.  He has no history of excessive snoring or apneic periods.  He has no history of falling asleep at work or while driving.  He has never had a formal sleep study.  He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS:  ,He denies any change in his appetite.  He has actually gained some weight in recent months.  He denies any nausea, vomiting, or abdominal discomfort.  He denies any pruritus.  He denies any lower extremity edema.  All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1.  Stage IV chronic kidney disease with most recent GFR of 22.,2.  HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3.  Hyperlipidemia.,4.  Hypertension.,5.  Secondary hyperparathyroidism.,6.  Status post right upper extremity AV fistula in the fall of 2006.,7.  History of a right brachial plexus palsy.,8.  Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:,  HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1.  Kaletra daily.,2.  Epivir one daily.,3.  Ziagen two daily.,4.  Lasix 20 mg b.i.d.,5.  Valsartan 20 mg b.i.d.,6.  Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD.  He is employed at the sales counter of a local butcher shop.  He continues to smoke one pack of cigarettes daily, as he has for the past 28 years.  He denies any alcohol or illicit substances.,FAMILY HISTORY:,  His mother is deceased.  He said that she had some type of paralysis before she died.  His father is deceased at age 64 of a head and neck cancer.  He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy.  He has a 41-year-old brother who has hypertension.  He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 191 pounds.  His temperature is 97.1.  Pulse is 94.  Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT:  His oropharynx is clear without thrush or ulceration.,NECK:  Supple without lymphadenopathy or thyromegaly.,HEART:  Regular with normal S1 and S2.  There are no murmurs, rubs, or gallops.  He has no JVD.,LUNGS:  Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN:  Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL:  He has difficulty with abduction of his right shoulder.,ACCESS:  He has a right forearm AV fistula with an audible bruit and a palpable thrill.  There is no sign of stenosis.  The vascular access looks like it is ready to use.,EXTREMITIES:  No peripheral edema.,SKIN:  No bruises, petechiae, or rash.,LABS:  ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18.  BUN is 49, creatinine 4.3.  GFR is 19.  Albumin 3.2.  Protein 7.  AST 17, ALT 16, alkaline phosphatase 106.  Total bilirubin 0.4.  Calcium 9.1., phosphorus 4.7, PTH of 448.  The corrected calcium was 9.7.  WBC is 8.9, hemoglobin 13.4, platelet 226.  Total cholesterol 234, triglycerides 140, LDL 159, HDL 47.  His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION:  ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1.  Renal.  His serum creatinine is progressively worsening.  His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3.  This represents a GFR of 19.  This is stage IV chronic kidney disease.  He does have vascular access and this appears to be ready to use.  He is having some difficulty sleeping and it is possible that this represents some early signs of uremia.  Otherwise, he has no signs or symptoms of uremia at this time.  I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes.  He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes.  I have encouraged him to continue to exercise his right forearm.  I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant.  Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2.  Hypertension.  I have added labetolol 100 mg b.i.d. to his antihypertensive regimen.  He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased.  Goal blood pressure would be less than 130/80.,3.  Hyperkalemia.  I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily.  I will have him return in one week to recheck his potassium.  If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4.  Bone metabolism.  His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals.  His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5.  Acid base.  His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6.  Anemia.  His hemoglobin is at goal for this stage of chronic kidney disease.  His iron stores are adequate.",Chronic Kidney Disease - Consult,Nephrology,
MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.,"CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to ""severe blurring"" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.",MRI Brain - Bilateral Thalamic Strokes,Neurology,"neurology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes,"
Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.,"PROCEDURES PERFORMED,1.  Insertion of subclavian dual-port Port-A-Cath.,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 general endotracheal anesthesia was administered.  Next, the chest was prepped and draped in a standard surgical fashion.  A #18-gauge spinal needle was used to aspirate blood from the subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire.  The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next a #15-blade scalpel was used to make an incision in the skin.  Dissection was carried down to the level of the pectoralis muscle.  A pocket was created.  A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene.  Both ports were flushed.  The distal tip was pulled through to the wire exit site with a Kelly clamp.  It was cut to the appropriate length.  Next a dilator and sheath were threaded over the J wire.  The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn.  Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty.  The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  The wire access site was closed with a 4-0 Monocryl.  The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition",Port-A-Cath Insertion - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.,"CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed "" lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block."" She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.",MRI Spine - Epidural Lipoma,Radiology,
The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,"TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.",Diagnostic Laparoscopy,Obstetrics / Gynecology,"obstetrics / gynecology, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,"
History of right leg pain.  Leg pain is no longer present.,"HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.",Leg Pain - Progress Note,Orthopedic,
"Aplastic anemia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone.","CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:",Aplastic Anemia Followup,Hematology - Oncology,
"Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.   Bilateral upper lobe cavitary lung masses.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.","PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.",Fiberoptic Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,"
"Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.","REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:",Consult - Coronary Artery Disease,Cardiovascular / Pulmonary,
"Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.","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.",Anemia - Consult,Hematology - Oncology,
"Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions.  Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.","PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.",TAH & Salpingo-oophorectomy & Lysis of Adhesions,Obstetrics / Gynecology,"obstetrics / gynecology, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy,"
Cardiac catheterization and coronary intervention report.,"EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.",Cardiac Catheterization - 10,Cardiovascular / Pulmonary,
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.,"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.",Barium Swallow Study Evaluation,Gastroenterology,"gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,"
Closure of gastrostomy placed due to feeding difficulties.,"PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.",Surgical Closure of Gastrostomy,Gastroenterology,"gastroenterology, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy"
Encephalopathy related to normal-pressure hydrocephalus.,"ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,",Encephalopathy  - Rehab Consult,Neurology,
"The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.","DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS:  ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:,  The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity.  There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees.  Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY:  ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return.  The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT:  ,The patient is a 58-year-old female with left knee osteoarthritis.  Examination indicates deficits in pain, muscle endurance, and functional mobility.  The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN:  ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1.  Modalities including electrical stimulation, ultrasound, heat, and ice.,2.  Therapeutic exercise.,3.  Functional mobility training.,4.  Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1.  The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2.  The patient is to perform standby assist transfer using a pickup walker.,3.  The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4.  The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1.  The patient is to be independent with the home exercise program.,2.  The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3.  The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:,  Fair to good.,The above treatment plan has been discussed with the patient.  She is in agreement.",Physical Therapy - Osteoarthritis,Orthopedic,
"Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.","PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.",ORIF - 2,Orthopedic,"orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial"
"Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.","FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and ""tension headaches.""  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.",Anterior Cervical Discectomy & Fusion - Discharge Summary,Orthopedic,"orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,"
"Suction dilation and curettage for incomplete abortion.  On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.","PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.","Suction, Dilation, & Curettage - 1",Obstetrics / Gynecology,"obstetrics / gynecology, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,"
Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.,"REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.",Consult - Atrial Fibrillation,Cardiovascular / Pulmonary,
"Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.","PROCEDURE: , Cardiac catheterization by:,a.  Left heart catheterization.,b.  Left ventriculography.,c.  Selective coronary angiography.,d.  Right femoral artery approach.,COMPLICATIONS:,  None.,MEDICATIONS,1.  IV Versed.,2.  IV fentanyl.,3.  Intravenous fluid administration.,4.  Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained.  Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed.  The patient was prepped, draped, and anesthetized in the usual manner.  Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery.  Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections.  Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections.  Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance.  Left ventricular angiogram was performed.  Pre and post angiogram LVEDP, LV, and aortic pressures were obtained.  At the end of the procedure catheters were removed and the introducer sheath was secured.  The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:,  LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal.  The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall.  Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction.  No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1.  ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch.  Angiographically the right coronary artery is normal.,2.  ,LEFT MAIN ARTERY:,  The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3.  ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex.  Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging.  The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment.  Otherwise, there is no evidence of atherosclerotic obstruction.,4.  ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex.  Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery.  These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome.  The patient will be treated medically.","Heart Catheterization, Ventriculography, & Angiography - 12",Cardiovascular / Pulmonary,
"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.","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.",Thoracoabdominal Aneurysm,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE"
"A complex closure and debridement of wound.  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.","TITLE OF OPERATION:,  A complex closure and debridement of wound.,INDICATION FOR SURGERY:,  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.  There is no evidence of fevers.  CRP was normal.  Shunt CT were all normal.  The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion.  Next, working on the fistula, this was elliptically excised.  Once this was excised, this was followed down to the fistulous tract, which was completely removed.  There was no CSF drainage.  The catheter was visualized, although not adequately properly.  Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied.  The patient was reversed, extubated and transferred to the recovery room in stable condition.  Multiple cultures were sent as well as the tracts sent to Pathology.  All sponge and needle counts were correct.",Wound Closure & Debridement - Hydrocephalus,Neurosurgery,"neurosurgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, surgery, draining, fistula, wound,"
Patient with complaints of significant coughing and wheezing.,"PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.",Pulmonary Consultation - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing,"
History and Physical for right ankle sprain,"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.",Ankle Sprain - H&P,Orthopedic,
"Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.","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.",Subclavian Central Venous Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion"
"Synovitis - anterior cruciate ligament tear of the left knee.  The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.   The patient fell in a grocery store.  He reports slipping on a grape that was on the floor.","DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.",Physical Therapy - Synovitis,Orthopedic,
"The patient is 14 months old, comes in with a chief complaint of difficulty breathing.","HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",Difficulty Breathing - ER Visit,Pediatrics - Neonatal,
"Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer.  The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.","CHIEF COMPLAINT:,1.  Chronic lymphocytic leukemia (CLL).,2.  Autoimmune hemolytic anemia.,3.  Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:,  Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES:  ,Vicodin.,REVIEW OF SYSTEMS:  ,The patient reports ulcer on his tongue and his lip.  He has been off of Valtrex for five days.  He is having some difficulty with his night vision with his left eye.  He has a known cataract.  He denies any fevers, chills, or night sweats.  He continues to have headaches.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:",Anemia & Leukemia Followup,Hematology - Oncology,"hematology - oncology, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune,"
"Patient with wrist pain and swelling, status post injury.","FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.",MRI Wrist - 1,Orthopedic,"orthopedic, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,"
MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.,"CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was ""normal"" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were ""up to date."",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.",MRI Brain - Pilocytic Astrocytoma,Neurology,"neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri,"
MRI Brain & T-spine - Demyelinating disease.,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.",MRI Brain & T-spine - Demyelinating disease.,Orthopedic,"orthopedic, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain,"
"Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.","PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.",Ethmoidectomy & Nasal Polypectomy,ENT - Otolaryngology,"ent - otolaryngology, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,"
"The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.","REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.",Neuroblastoma - Consult,Neurology,
Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy.,"PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.",Colonoscopy - 18,Gastroenterology,"gastroenterology, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel,"
"Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.","PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.",Bronchoscopy - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,"
"Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.","CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.",Mantle Cell Lymphoma - Consult,Hematology - Oncology,
Endoscopic subperiosteal midface lift using the endotine midface suspension device.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,"PREOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,PROCEDURES:,1.  Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  She had requested a procedure to bring about further facial asymmetry.  She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  Preoperative workup including CT scan failed to show any skeletal trauma.  The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:,  The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  General endotracheal anesthesia was induced with a #6 endotracheal tube.  All appropriate measures were taken to preserve the vocal cords in a professional singer.  Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine.  Adequate time for vasoconstriction and anesthesia was allowed to be obtained.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture was placed in the right lower lid.  For traction, it was brought anteriorly.  The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe.  A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  The inferior oblique muscle was identified, preserved, and protected throughout the procedure.  The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  Contralateral side was treated in similar fashion with like results and throughout the procedure.  Lacri-Lube was in the eyes in order to maintain hydration.  Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle.  The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  It was bipolar electrocauteried and the tunnel was further dissected free and opened.  The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  The guard was removed and the suspension spikes were engaged into the soft tissues.  The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture.  Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  The sterile dressing was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.",Midface Lift & Blepharoplasty,Ophthalmology,"ophthalmology, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,"
"Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.","PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.",Lobectomy & Lymphadenectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest"
Tonsillectomy and adenoidectomy.  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,"PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.",Tonsillectomy & Adenoidectomy - 3,ENT - Otolaryngology,"ent - otolaryngology, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads"
"Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.","OPERATION,1.  Ivor-Lewis esophagogastrectomy.,2.  Feeding jejunostomy.,3.  Placement of two right-sided #28-French chest tubes.,4.  Right thoracotomy.,ANESTHESIA:  ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  In addition, he had a dual-lumen endotracheal tube placed.  The patient was placed in the supine position to begin the procedure.  His abdomen and chest were prepped and draped in the standard surgical fashion.  After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  Dissection was carried down through the linea using Bovie electrocautery.  The abdomen was opened.  Next, a Balfour retractor was positioned as well as a mechanical retractor.  Next, our attention was turned to freeing up the stomach.  In an attempt to do so, we identified the right gastroepiploic artery and arcade.  We incised the omentum and retracted it off the stomach and gastroepiploic arcade.  The omentum was divided using suture ligature with 2-0 silk.  We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  Next, we turned our attention to performing a Kocher maneuver.  This was done and the stomach was freed up.  We took down the falciform ligament as well as the caudate attachment to the diaphragm.  We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  We also did a portion of the esophageal dissection from the abdomen into the chest area.  The esophagus and the esophageal hiatus were identified in the abdomen.  We next turned our attention to the left gastric artery.  The left gastric artery was identified at the base of the stomach.  We first took the left gastric vein by ligating and dividing it using 0 silk ties.  The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  At this point the stomach was freely mobile.  We then turned our attention to performing our jejunostomy feeding tube.  A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz.  We then used Bovie electrocautery to open the jejunum at this site.  We placed a 16-French red rubber catheter through this site.  We tied down in place.  We then used 3-0 silk sutures to perform a Witzel.  Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  This was done with #1 Prolene.  We put in a 2nd layer of 2-0 Vicryl.  The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure.  The patient was placed in the left lateral decubitus position.  The right chest was prepped and draped appropriately.  We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  Dissection was carried down to the level of the ribs with Bovie electrocautery.  Next, the ribs were counted and the 5th interspace was entered.  The lung was deflated.  We placed standard chest retractors.  Next, we incised the peritoneum over the esophagus.  We dissected the esophagus to just above the azygos vein.  The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring.  We used an automatic pursestring and applied.  We then transected the proximal portion of the stomach with Metzenbaum scissors.  We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  The pursestring was then tied down without difficulty.  Next, we tabularized our stomach using a #80 GIA stapler.  After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery.  We placed our EEA stapler through it and then punched out through the gastric wall.  We connected our anvil to the EEA stapler.  This was then secured appropriately.  We checked to make sure that there was appropriate muscle apposition.  We then fired the stapler.  We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  We also sent the gastroesophageal specimen for pathology.  Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  We then turned our attention to closing the gastrostomy opening.  This was closed with 2-0 Vicryl in a running fashion.  We then buttressed this with serosal 3-0 Vicryl interrupted sutures.  We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion.  The lung was brought up.  We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition.","Esophagogastrectomy, Jejunostomy, & Chest Tubes",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach,"
Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).  She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,"REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.",PAF - 6-Month Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial,"
"Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.","PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:,  Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing.  Risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,FINDINGS:  ,The patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia.  The left ear was then draped in a clean fashion.  Under microscopic visualization, the ear canal was cleaned of the wax.  Myringotomy incision was made in the anterior inferior quadrant.  There was no fluid in the middle ear space.  A Micron Bobbin tube was easily placed.  Floxin drops were placed in the ear.  The same was performed on the right side with similar findings.  The patient was then turned to be placed in Rose position.  The patient draped in clean fashion.  A small McIvor mouth gag was used to hold open the oral cavity.  The soft palate was palpated.  There was no submucous cleft felt.  Using a 1:1 mixture of 1% Xylocaine with 1:100,000 epinephrine and 0.25% Marcaine, both tonsillar pillars and the fossae injected with approximately 7 mL total.  Using a curved Allis the right tonsil was grasped and pulled medially.  Tonsil was dissected off the tonsillar fossa using a Coblator.  The left tonsil was removed in the similar fashion.  Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting.  The soft palate was then retracted using red rubber catheter.  Under mirror visualization, the patient was found to have enlarged adenoids.  The adenoids were removed using the Coblator.  Hemostasis was also achieved using the Coblator on coagulation setting.  The rubber catheter was then removed.  Reexamining the oropharynx, small bleeding points were cauterized with the Coblator.  Stomach contents were then aspirated with saline sump.  The patient was woken up from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge correct.  Estimated blood loss minimal.",BMT & T&A,ENT - Otolaryngology,"ent - otolaryngology, bilateral myringotomy, tube placement, tonsillectomy, adenoidectomy, micron bobbin, myringotomy and tube, tonsillectomy and adenoidectomy, chronic otitis media, tonsillar adenoid, tonsillar fossa, rubber catheter, otitis media, adenoids, myringotomy, otitis, media, tonsillar, coblator,"
"Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.","PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.",Selective Coronary Angiography & Angioplasty,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,"
"Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.","PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.",Rhytidectomy & Blepharoplasty,Ophthalmology,"ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,"
Cardiology office visit sample note.,"HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.",Cardiology Office Visit - 2,Cardiovascular / Pulmonary,
CT Brain: Midbrain hemangioma,"CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of ""dystonia."",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild ""ataxia"" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.",CT Brain - Hemangioma,Neurology,"neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal,"
Closed reduction and pinning of the right ulna with placement of a long-arm cast.,"PREOPERATIVE DIAGNOSIS:,  Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:,  Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE:  ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007.  The patient was seen in the emergency room.  The patient had a complete fracture of both bones with shortening bayonet apposition.  Treatment options were offered to the family including casting versus closed reduction and pinning.  The parents opted for the latter.  Risks and benefits of surgery were discussed.  Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness.  All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The right upper extremity was then prepped and draped in standard surgical fashion.  A small incision was made at the tip of the olecranon.  Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal.  This was changed for a 0.79 K-wire.  This was driven up to the fracture site.  The fracture was manually reduced and then the K-wire passed through the distal segment.  This demonstrated adequate fixation and reduction of both bones.  The pin was then cut short.  The fracture site and pin site was infiltrated with 0.25% Marcaine.  The incision was closed using 4-0 Monocryl.  The wounds were cleaned and dried.  Dressed with Xeroform, 4 x 4.  The patient was then placed in a well-moulded long-arm cast.  He tolerated the procedure well.  He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal.  X-rays of the right forearm will be taken.  The patient may need additional mobilization time.  Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months.  Intraoperative findings were relayed to the parents.  All questions were answered.",Pinning - Ulna,Orthopedic,"orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast,"
MRI T-spine and CXR - Aortic Dissection.,"CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden ""pressure-like"" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and ""went to sleep."" The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was ""normal."" The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.",MRI T-Spine,Orthopedic,"orthopedic, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine,"
Colonoscopy in a patient with prior history of anemia and abdominal bloating.,"PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.",Colonoscopy - 2,Gastroenterology,"gastroenterology, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope,"
Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal.,"PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.",Bronchoscopy & Foreign Body Removal,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy,"
GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.,"CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.",GI Bleed - Discharge Summary,Gastroenterology,
"The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.","CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.",Consult - Breast Cancer - 1,Hematology - Oncology,
Lateral release with lengthening of the ECRB tendon.  Lateral epicondylitis.,"PREOPERATIVE DIAGNOSIS:  ,Lateral epicondylitis.",Lateral Epicondylitis Release,Orthopedic,"orthopedic, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb"
"Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.","INDICATION: , This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery.  He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy.  He has recently completed radiation therapy to T11 for a plasmacytoma.  He has recently complained of left anterior chest pain, which radiates down the left upper arm towards the elbow.  This occurs during quiet periods such as in bed at night.  It may last all night and still be present in the morning.  It usually dissipates as the day progresses.  There are no obvious triggers and there are no obvious alleviating factors.  The patient has no known cardiac risk factors.  He is currently taking Avodart 0.5 mg daily, Wellbutrin 300 mg daily, Xanax 0.25 mg p.r.n., Uroxatral 10 mg daily, and omeprazole 20 mg daily.,PHYSICAL EXAMINATION: , On physical examination, the patient appears pale and fatigued.  He is 66 inches tall, 205 pounds for a body mass index of 32.  His resting heart rate is 80.  His resting blood pressure is 120/84.  His lungs are clear.  His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated.  The carotid upstroke is normal with no bruit identified.  The peripheral pulses are intact.  The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.,DESCRIPTION: , The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue.  He did not experience his left anterior chest pain with exercise.  He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate.  His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs.  As noted the resting electrocardiogram was normal.  With exercise, there were no significant deviations from baseline and no arrhythmias.,CONCLUSION:,1.  Reduced exercise capacity for age.,2.  No chest pain with exercise.,3.  No significant ST segment changes with exercise.,4.  Symptoms of left anterior chest pain were not provoked with exercise.,5.  Hypertensive response noted with exercise.",Exercise Stress Test - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, regular rhythm, s1, s2, chest pain, hypertensive, bruce protocol, exercise stress test, blood pressure, resting electrocardiogram, anterior chest, heart rate, rhythm, electrocardiogram, stress, chest, heart"
"Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.","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.",Angina - Consult,Cardiovascular / Pulmonary,
"Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.","PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.",Ear Cartilage Graft,ENT - Otolaryngology,"ent - otolaryngology, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis"
Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws.,"PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.",AC Separation Revision & Hardware Removal,Orthopedic,"orthopedic, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware"
"Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.","REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.",Pulmonary Embolism,Cardiovascular / Pulmonary,
Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.,"HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,",Pain Management Consult - 2,Orthopedic,
CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,"PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.",Frameless Stereotactic Radiosurgery,Neurology,"neurology, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,"
"Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.","PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,",Anterior Cervical Discectomy & Fusion - 9,Neurosurgery,"neurosurgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium"
Ruptured globe with full-thickness corneal laceration repair - Sample/Template.,"PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.",Ruptured Globe Repair - Cornea,Ophthalmology,"ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,"
A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain.  MI has been ruled out.  She has been referred for an exercise echocardiogram.,"Informed written consent has been obtained from the patient.  I explained the procedure to her prior to initiation of such.  The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position.  There were no safety concerns noted by staff nor myself.,REST ECHO:,  EF 60%.  No wall motion abnormalities.  EKG shows normal sinus rhythm with mild ST depressions.  The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen.  Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities.  There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise.  No dysrhythmias noted.,IMPRESSION:,1.  Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2.  Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient.  Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.",Exercise Stress Test - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram"
Duplex ultrasound of legs,"DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.",Duplex Ultrasound - Legs,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,"
"Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.","PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.",Double Lumen Port Inserstion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter,"
Consultation for left foot pain.,"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.",Foot pain Consultation,Orthopedic,"orthopedic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness"
"A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.","IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , ""I am not sure."" The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia ""they want to hurt me."",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.",Psych Consult - Paranoia,Psychiatry / Psychology,
MRI Elbow - A middle-aged female complaining of elbow pain.,"FINDINGS:,There is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal T2 image #1452, sagittal T2 image #1672). There is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,There is a joint effusion of the radiocapitellar articulation with mild fluid distention.,The radial collateral (proper) ligament remains intact. There is periligamentous inflammation of the lateral ulnar collateral ligament (coronal T2 image #1484) of the radial collateral ligamentous complex. There is no articular erosion or osteochondral defect with no intra-articular loose body.,There is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial T2 image #1324). The common flexor tendon otherwise is normal.,There is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal T2 image #1516, axial T2 image #1452) with an intrinsically normal ligament.,The ulnotrochlear articulation is normal.,The brachialis and biceps tendons are normal with a normal triceps tendon. The anterior, posterior, medial and lateral muscular compartments are normal.,The radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,IMPRESSION:,Lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,Periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,Small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,Mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,Minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament.",MRI Elbow - 1,Orthopedic,"orthopedic, radial collateral ligamentous complex, intra articular loose body, axial t image, ulnar collateral ligament, common flexor tendon, mri elbow, ligamentous complex, radial collateral, ulnar collateral, collateral ligament, flexor tendon, periligamentous inflammation, mri, tendon"
"Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.","PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.",Abdominal Abscess I&D,Gastroenterology,"gastroenterology, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess,"
CT Abdomen and Pelvis with contrast,"EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day.  Fever.  Right upper quadrant pain for one day.  ,COMPARISON: , None. ,TECHNIQUE:,  CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.  ,CT ABDOMEN: , Lung bases are clear.  The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  The aorta is normal in caliber.  There is no retroperitoneal lymphadenopathy.  ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  Per CT, the colon and small bowel are unremarkable.  The bladder is distended.  No free fluid/air.  Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Unremarkable exam; specifically no evidence for acute appendicitis. ,2.  No acute nephro-/ureterolithiasis. ,3.  No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.",CT Abdomen & Pelvis - 1,Gastroenterology,"gastroenterology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct"
Coil embolization of patent ductus arteriosus.,"HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus.  An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt.  There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821.  An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy.  The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE:  ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt.  Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm.  The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta.  This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta.  Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery.  Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter.  Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus.  The left-sided heart was fully saturated.  The phasic right-sided and left-sided pressures were normal.  The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt.  The branch pulmonary arteries appeared normal.  There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation.  No evidence of residual left-to-right shunt.  There is no change in right-sided pressures.  There is a slight increase in the left-sided phasic pressures.  Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1.  Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery.  There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS):  ,Coil embolization of patent ductus arteriosus.,MANAGEMENT:  ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram.  Further patient care be directed by Dr. X.,",Patent Ductus Arteriosus,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization"
"Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:,  Recurrent angina.  History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:,  6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide.  Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range.  There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1.  Ventriculogram:  Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2.  Right coronary artery:  Dominant.  There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3.  Left coronary artery:  The left main coronary artery showed insignificant disease.  The circumflex arose, showed about 30% proximally.  Left anterior descending arose and the previously placed stent was perfectly patent.  There was a large diagonal branch which showed 90% stenosis in its proximal portion.  There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  He desired that we intervene.,Successful stenting of the left anterior descending, diagonal.  The guide was placed in the left main.  We easily crossed the lesion in the diagonal branch of the left anterior descending.  We advanced, applied and post-dilated the 275 x 13 stent.  Final angiography showed 0% residual at the site of previous 90% stenosis.  The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1.  Successful stenting of the left anterior descending/diagonal.  Initially there was 90% in the diagonal after stenting.  There was 0% residual.  There was a lesion a bit more proximal in the 40% range.,2.  Left anterior descending stent remains patent.,3.  30% in the circumflex.,4.  60% in the right coronary.,5.  Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion.  The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy.  We used 6-French Angio-Seal in the groin.  All questions have been answered.  I have discussed the possibility of restenosis, need for further procedures.","Heart Catheterization, Ventriculography, & Angiography - 2",Cardiovascular / Pulmonary,
"A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.","CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-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.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No",Otitis Media - H&P,Pediatrics - Neonatal,
"Exercise stress test with nuclear scan for chest pain.  Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product.  Normal nuclear myocardial perfusion scan.","INDICATION:  ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60.  EKG normal sinus rhythm.  The patient exercised on Bruce for 8 minutes on stage III.  Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54.  Total METs was 10.1.  EKG revealed nonspecific ST depression in inferior and lateral leads.  The test was terminated because of fatigue.  The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1.  Positive exercise ischemia with ST depression 0.5 mm.,2.  Chest pain resolved after termination of exercise.,3.  Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 68%.  End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction of 68% by gated SPECT.",Exercise Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest"
"Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.","PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.",Needle Localized Excision - Breast Neoplasm,Obstetrics / Gynecology,"obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast"
Left partial nephrectomy due to left renal mass.,"PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.",Nephrectomy - Partial,Nephrology,"nephrology, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,"
"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.","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.",Thoracotomy & Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,"
"Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.","PROCEDURE: , Cardiac catheterization by:,a.  Left heart catheterization.,b.  Left ventriculography.,c.  Selective coronary angiography.,d.  Right femoral artery approach.,COMPLICATIONS:,  None.,MEDICATIONS,1.  IV Versed.,2.  IV fentanyl.,3.  Intravenous fluid administration.,4.  Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained.  Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed.  The patient was prepped, draped, and anesthetized in the usual manner.  Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery.  Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections.  Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections.  Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance.  Left ventricular angiogram was performed.  Pre and post angiogram LVEDP, LV, and aortic pressures were obtained.  At the end of the procedure catheters were removed and the introducer sheath was secured.  The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:,  LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal.  The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall.  Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction.  No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1.  ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch.  Angiographically the right coronary artery is normal.,2.  ,LEFT MAIN ARTERY:,  The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3.  ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex.  Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging.  The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment.  Otherwise, there is no evidence of atherosclerotic obstruction.,4.  ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex.  Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery.  These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome.  The patient will be treated medically.","Heart Catheterization, Ventriculography, & Angiography - 12",Cardiovascular / Pulmonary,
A female for a complete physical and follow up on asthma with allergic rhinitis.,"SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.",Followup on Asthma,Cardiovascular / Pulmonary,
The patient was running and twisted her right ankle - right ankle sprain.,"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.",Ankle Pain - Consult,Orthopedic,
Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation.,"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",Psychosocial Eval - Donor - 1,Psychiatry / Psychology,
Arterial imaging of bilateral lower extremities.,"INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.",Arterial Imaging,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,"
"Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.","PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,OPERATIONS:,1.  Abdominosacrocolpopexy.,2.  Enterocele repair.,3.  Cystoscopy.,4.  Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:,  The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars.  Risk of open surgery was little bit higher for the patient.  After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed.  The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  The patient was told to perform no heavy lifting for 3 months, etc.  The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Pfannenstiel low abdominal incision was done at the old incision site.  The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  The muscle was split in the middle and peritoneum was entered using sharp mets.  There was no injury to the bowel upon entry.  There were significant adhesions which were unleashed.  All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  There was minimal space, everything was packed, Bookwalter placed then over the sacral bone.  The middle of the sacral bone was identified.  The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3.  A 1 cm x 5 cm mesh was cut out.  This was a Prolene soft mesh which was tied at the sacral ligament.  The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3.  The mesh was attached.  The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty.  The ureter was not involved at all in this process.  The peritoneum was closed over the mesh.  Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  Prior to closure antibiotic irrigation was done using Ancef solution.  The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution.  All the solution was removed.  Good hemostasis was obtained.  All the packing was removed.  Count was correct.  Rectus abdominus muscle was brought together using 4-0 Vicryl.  The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle.  Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion.  Cystoscopy was done at the end of the procedure.  Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  Cystoscopy was done and indigo carmine has been given.  There was good efflux of indigo carmine in both of the ureteral opening.  There was no injury to the rectum or the bladder.  The bladder appeared completely normal.  The rectal exam was done at the end of the procedure after the cystoscopy.  After the cysto was done, the scope was withdrawn, Foley was placed back.  The patient was brought to recovery in the stable condition.",Abdominosacrocolpopexy,Obstetrics / Gynecology,"obstetrics / gynecology, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy,"
"Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.","PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.",Medial Branch Rhizotomy,Orthopedic,"orthopedic, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,"
"A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.","ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.",Cardio/Pulmo Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,"
"Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.","PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.",Anterior Cervical Decompression,Neurosurgery,"neurosurgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,"
Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan.,"INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.",Adenosine Nuclear Scan,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,"
A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.,"PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1.  Flexible bronchoscopy.,2.  Mediastinoscopy.,3.  Right thoracotomy.,4.  Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1.  Radiation Oncology.,2.  Pulmonary Medicine.,3.  Medical Oncology.,4.  Cancer Center Team consult.,5.  Massage therapy consult.,HOSPITAL COURSE:,  The patient's hospital course was unremarkable.  Her pain was well controlled with an epidural that was placed by Anesthesia.  At the time of discharge, the patient was ambulatory.  She was discharged with home oxygen available.  She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d.  She was discharged with a prescription for Vicodin for pain control.  She is to follow up with Dr. X in the office in one week with a chest x-ray.  She is instructed not to lift, push or pull anything greater than 10 pounds.  She is instructed not to drive until after she sees us in the office and is off her pain medications.",Discharge Summary - Mesothelioma,Hematology - Oncology,"hematology - oncology, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,"
"Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.","REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.",Lung Cancer & MI - Hospice Cosult,Cardiovascular / Pulmonary,
Noncontrast CT abdomen and pelvis per renal stone protocol.,"EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.",CT Stone Protocol,Nephrology,"nephrology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,"
Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.,"DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.",Myoclonic Epilepsy,Neurology,"neurology, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure"
"Coronary artery bypass grafting (CABG) x4.  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.","PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:,  Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina.  He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function.  He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE:  ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp.  Left internal mammary artery and saphenous vein grafts were good quality conduits.  Radial artery graft was a smaller sized conduit, otherwise good quality.  All distal targets showed heavy plaque involvement with calcification present.  The smallest target was the PDA, which was about 1.5 mm in size.  All the other targets were about 2 mm in size or greater.  The patient came off cardiopulmonary bypass without any problems.  He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips.  Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE:  ,The patient was brought into the operating room and laid supine on the table.  After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately.  The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion.  Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed.  Left internal mammary artery was taken down.  Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques.  Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques.  Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given.  Pericardium was opened and suspended.  During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally.  Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended.  Pursestring sutures were placed.  Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass.  With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia.  An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first.  The right coronary artery was calcified along its course all the way to its terminal bifurcation.  Even in the PDA, calcification was noted in a spotty fashion.  Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions.  End radial to side PDA anastomosis was constructed using running 7-0 Prolene.  Next, the posterolateral obtuse marginal was exposed.  Arteriotomy was performed.  An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene.  This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene.  Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD.  LAD was exposed.  Arteriotomy was performed.  An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene.  LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch.  Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene.  The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed.  Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity.  Temporary V-pacing wires were placed.  Blake drains were placed in the left chest, the right chest, as well as in the mediastinum.  Left chest Blake drain was placed just in the medial section where dissection had been performed.  After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems.  With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine.  Decannulation was performed after volume resuscitation.  Hemostasis was assured.  Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure.  Dressings were applied.  The patient was transferred to the ICU in stable condition.  He tolerated the procedure well.  All counts were correct at the termination of the procedure.  Cross clamp time was 102 minutes.  Bypass time was 120 minutes.  The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.",CABG x5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, radial artery, lima, pda, obtuse marginal, exertional angina, coronary artery disease, triple-vessel, graft, conduit, ij triple-lumen catheter, cordis catheter, a-line, foley catheter, tee probes, coronary artery bypass grafting, cross clamp, mammary artery, saphenous vein, coronary artery, artery, cabg, coronary, grafting, aorta, angina, bypass"
CT Abdomen & Pelvis W&WO Contrast,"EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.",CT Abdomen & Pelvis,Nephrology,"nephrology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,"
"Pain and swelling in the right foot, peroneal tendon tear.","EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,",MRI Foot - 1,Orthopedic,"orthopedic, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,"
"Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.","PRINCIPAL DIAGNOSIS:,  Mesothelioma.,SECONDARY DIAGNOSES:,  Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1.  On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2.  On August 20, 2007, thoracentesis.,3.  On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week.  She has had right-sided chest pain radiating to her back with fever starting yesterday.  She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center.  Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1.  Pericardectomy.,2.  Pericarditis.,2.  Atrial fibrillation.,4.  RNCA with intracranial thrombolytic treatment.,5",Discharge Summary - Mesothelioma - 1,Hematology - Oncology,
Left heart cardiac catheterization.,"PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.",Cardiac Catheterization - 8,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending"
Ligament reconstruction and tendon interposition arthroplasty of right wrist.,"OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",Ligament Reconstruction & Tendon Interposition Arthroplasty,Orthopedic,"orthopedic, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition,"
Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.,"REASON FOR CONSULTATION:,  Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain.  The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:,  Not contributory.,PHYSICAL EXAMINATION:,GENERAL:  Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT:  Normocephalic and atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  Trachea is midline.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender, and nondistended.  Normoactive bowel sounds.,EXTREMITIES:  No clubbing, edema, or cyanosis.,SKIN:  The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:,  As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:,  At this time, the CT Surgery service has been consulted and has left recommendations.  The patient also is awaiting bronchoscopy per the Pulmonary Service.  At this time, there are no General Surgery issues.",Pneumothorax & Subcutaneous Emphysema,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema,"
CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,"PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.",Frameless Stereotactic Radiosurgery,Neurosurgery,"neurosurgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,"
"Diagnostic laparoscopy and laparoscopic appendectomy.  Right lower quadrant abdominal pain, rule out acute appendicitis.","PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation.  She admits to some nausea associated with it.  There have been no fevers, chills, and/or genitourinary symptoms.  The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant.  She had a leukocytosis of 12.8.  She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis.  Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy.  The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS:  ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged.  The left ovary revealed some follicular cysts.  There was no evidence of adnexal masses and/or torsion of the fallopian tubes.  The uterus revealed no evidence of mass and/or fibroid tumors.  The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient underwent general endotracheal anesthesia.  The patient also received a preoperative dose of Ancef 1 gram IV.  After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle.  Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg.  Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty.  A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored.  Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region.  This was inserted under direct visualization.  Finally, a suprapubic 12 mm portal was created.  This was performed with #10 blade scalpel to create a transverse incision.  A bladed trocar was inserted into the suprapubic region.  This was done again under direct visualization.  Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum.  This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly.  Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device.  Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device.  The staple line was visualized and there was no evidence of bleeding.  The abdomen was fully irrigated with copious amounts of normal saline.  The abdomen was then aspirated.  There was no evidence of bleeding.  All ports were removed under direct visualization.  No evidence of bleeding from the port sites.  The infraumbilical and suprapubic ports were then closed.  The fascias were then closed with #0-Vicryl suture on a UR6 needle.  Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl.  The areas were cleaned, Steri-Strips were placed across the wound.  Sterile dressing was applied.,The patient tolerated the procedure well.  She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition.  She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.",Laparoscopy & Laparoscopic Appendectomy,Gastroenterology,"gastroenterology, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic,"
Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.,"PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.",Bronchoscopy - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretionsNOTE"
Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.,"EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION:  ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe.  The lower lobe appears aerated.  There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation.  The heart and pulmonary vascularity are within normal limits.  Left-sided port is seen with Groshong tip at the SVC/RA junction.  No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2.  Rest of visualized exam nonacute/stable.,3.  Left central line appropriately situated and stable.,4.  Preliminary report was issued at time of dictation.  Dr. X was called for results.",Chest PA & Lateral,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax,"
"Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.","The patient states that she has been doing fairly well at home.  She balances her own checkbook.  She does not do her own taxes, but she has never done so in the past.  She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving.  She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home.  She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren.  She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression.  There is unfortunately no one available to us to corroborate how well she is doing at home.  She lives alone and takes care of herself and does not communicate very much with her brother and sister.  She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren.  She denied any sort of personality change, paranoid ideas or hallucinations.  She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it.  When these headaches are very severe, she goes to the emergency room to get a single shot.  She is unclear if this is some sort of a migraine medication or just a primary pain medication.  She takes Fiorinal for these headaches and she states that this helps greatly.  She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia.  She also denies any sort of movement disorders, tremors, rigidities or clonus.  Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness.  She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago.  The patient was not sure of exactly when it was diagnosed.  This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations.  The mesothelioma is in her abdomen.  She does not know of any history of having lung mesothelioma.  She states that she has never gotten chemotherapy or radiation for her mesothelioma.  Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable.  She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position.  These have all occurred over the past five years.  She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation.  This diagnosis was given in March 2006.,MEDICATIONS:,  Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:,  Significant for her being without a companion at this point.  She was born in Munich, Germany.  She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time.  She is divorced.  She used to work as a secretary and later worked as a clerical worker at IBM.  She stopped working more than 20 years ago due to complications from her mesothelioma.  She denies any significant tobacco, alcohol or illicit drugs.  She is bilingual speaking, German and English.  She has known English from before her teens.  She has the equivalent of a high school education in Germany.  She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them.  She has one son who lives in Santa Cruz.  He has grandchildren.  She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer.  Her mother died in her 80s of ""old age,"" but it appears that she may have had a mild dementing illness at that time.  Whatever that dementing illness was, appears to have started mostly in her 80s per the patient.  No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg.  She is alert and well nourished in no apparent distress.  She occasionally fumbles with questions of orientation, missing the day and the date.  She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in.  She lost three points for recall.  Even with prompting, she could not remember the objects that she was given to remember.  Her Mini Mental Score was 22/30.  There were no naming problems or problems with repetition.  There were also no signs of dysarthria.  Her pupils were bilaterally reactive to light and accommodation.  Her extraocular movements were intact.  Her visual fields were full to confrontation.  Her sensations of her face, arm, and leg were normal.  There were no signs of neglect with double simultaneous stimulation.  Tongue was midline.  Her palate was symmetric.  Her face was symmetric as well.  Strength was approximately 5/5.  She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain.  Her reflexes were symmetric and +2 except for her toes, which were +1 to trace.  Her plantar reflexes were mute.  Her sensation was normal for pain, temperature, and vibration.  There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia.  Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:,  Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type.  We tactfully discussed the patient's diagnosis with her, and she felt reassured.  We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept.  She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept.  The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV.  It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment.  She will follow up with us in the next six months and will call us if she has any problems with the Aricept.  She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day.  We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,",Consult - Alzheimer disease,Neurology,"neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,"
MRI Brain: Subacute right thalamic infarct.,"CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.",MRI Brain: Thalamic Infarct,Neurology,"neurology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain,"
"Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.","EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.",Cardiac Catheterization - 10,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft"
"Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.","DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,",Myocardial Perfusion Imaging - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial,"
Psychiatric Consultation of patient with major depression disorder.,"REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.",Psych Consult - Depression - 0,Psychiatry / Psychology,
Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.,"PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:,  Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES:  ,1.  Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  At that same time, the patient's mildly angulated radial shaft fracture will be reduced.  This was explained to the father.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  All questions were answered.  The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The left upper extremity was then prepped and draped in the standard surgical fashion.  Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  It was decided at this time that she would need open reduction.  The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg.  The Esmarch was then removed.  An incision was then made.  Care was taken to avoid any injury to the ulnar nerve.  The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  This was easily removed.  The ulnar nerve was also identified, and appeared to be intact.  The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl.  The wound was clean and dry, dressed with Steri-Strips and Xeroform.  The area was infiltrated with 0.5% Marcaine.  The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  The father was made aware of the intraoperative findings.  All questions answered.",ORIF & Closed Reduction,Orthopedic,"orthopedic, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve,"
"Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.","PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.",Pyeloplasty - Robotic,Nephrology,"nephrology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,"
"A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.","REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",Neuropsychological Evaluation - 3,Neurology,
This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.,"FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.",CT Lumbar Spine - 1,Neurology,"neurology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging,"
Echocardiogram and Doppler,"DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,",2-D Echocardiogram - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve"
Foul-smelling urine and stomach pain after meals.,"CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  ""Smelly"" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,",Foul-Smelling Urine,Gastroenterology,
An example of normal ENT exam.,"NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.",Sample Normal Exam - ENT,ENT - Otolaryngology,"ent - otolaryngology, ent exam, boggy mucosa, inferior turbinates, nasal septum, nose, oral cavity, rhinoscopy, submaxillary ducts, tongue, neck, submaxillary, parotid, parotid and submaxillary, extraocular movements, ent, nasal"
Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,"DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.",COPD & Bronchitis - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,"
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.,"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.",Arm Pain - Neuro Consult,Neurology,
"A right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident with no specific injury at that time.","HISTORY: , The patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in September of 2005.  At that time, she did not notice any specific injury.  Five days later, she started getting abnormal right low back pain.  At this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf.  Symptoms are worse when sitting for any length of time, such as driving a motor vehicle.  Mild symptoms when walking for long periods of time.  Relieved by standing and lying down.  She denies any left leg symptoms or right leg weakness.  No change in bowel or bladder function.  Symptoms have slowly progressed.  She has had Medrol Dosepak and analgesics, which have not been very effective.  She underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day.  This was done four and a half weeks ago.,On examination, lower extremities strength is full and symmetric.  Straight leg raising is normal.,OBJECTIVE:,  Sensory examination is normal to all modalities.  Full range of movement of lumbosacral spine.  Mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint.  Deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and F-waves are normal in the lower extremities.  Right tibial H-reflex is slightly prolonged when compared to the left tibial H-reflex.,NEEDLE EMG:,  Needle EMG was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle.  It revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle.  There were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A mild right L5 versus S1 radiculopathy.,2.  Left S1 nerve root irritation.  There is no evidence of active radiculopathy.,3.  There is no evidence of plexopathy, myopathy or peripheral neuropathy.,MRI of the lumbosacral spine was personally reviewed and reveals bilateral L5-S1 neuroforaminal stenosis, slightly worse on the right.  Results were discussed with the patient and her daughter.  I would recommend further course of spinal epidural injections with Dr. XYZ.  If she has no response, then surgery will need to be considered.  She agrees with this approach and will followup with you in the near future.",EMG/Nerve Conduction Study - 3,Neurology,"neurology, emg, nerve conduction study, radiculopathy, peripheral neuropathy, nerve root irritation, motor vehicle accident, lumbosacral paraspinal muscles, spinal epidural, lumbosacral spine, peroneus longus, gastrocnemius medialis, lower extremities, emg/nerve, conduction, needle"
"Cardiomyopathy and hypotension.  A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.","REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY:",Cardiomyopathy & Hypotension - Consult,Cardiovascular / Pulmonary,
"Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.  CT abdomen without contrast and CT pelvis without contrast.","CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.",CT Abdomen & Pelvis - 10,Gastroenterology,"gastroenterology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,"
"Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.","PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.",Diverticulectomy & Laparotomy,Gastroenterology,
Thoracentesis.  Left pleural effusion.  Left hemothorax.,"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,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest,"
"Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.","PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.",Cardiac Allograft Transplant,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery"
"Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.  Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.","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.",Thrombectomy AV Shunt,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt,"
Pulmonary Function Test in a patient with smoking history.,"HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%.  FEV1 was 45%.  FEV1/FVC ratio was 52%. The predicted was 67%.  FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  SVC was 91%. Inspiratory capacity was 70%.  Residual volume was 225% of its predicted.  Total lung capacity was 128%.  ,IMPRESSION:,1.  Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  Probably there is some restrictive element because of fibrosis.  The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  Diffusion capacity was not measured.  The flow volume loop was consistent with the above.,",Pulmonary Function Test - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function,"
Resting Myoview and adenosine Myoview SPECT,"PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.",Mayoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,"
The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.,"IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.  It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:,  Prior to admission, we do not have that information.  He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY:  ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude:  The patient is unresponsive.,Appearance:  He is lying in bed in the fetal position with a blanket over his head.,Psychomotor:  Catatonic.,EPS/TD:  Unable to assess though his limbs are quite contracted.,Affect:  Unresponsive.,Mood:  Unresponsive.,Speech:  Unresponsive.,Thought Process And Thought Content:  Unresponsive.,Psychosis:  Unable to elicit information to make this assessment.,Suicidal/Homicidal:  Also unable to elicit this information.,Cognitive Assessment:  Unable to elicit.,Judgment And Insight:  Unable to elicit.,Assets:  The patient is young.,Limitations:  Severe decompensation.,FORMULATION:  ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I:  Psychosis, NOS.,AXIS II:  Deferred.,AXIS III:  Dehydration.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1.  Stabilize medically from the dehydration per internal medicine.,2.  Medications, milieu therapy to assist with re-compensation.",Psych Consult - Psychosis - 1,Psychiatry / Psychology,
"Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.","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.",Breast Calcifications - Preop Consult,Obstetrics / Gynecology,
"Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.","REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.",Elevated BNP - Consult,Cardiovascular / Pulmonary,
"Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.","REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.",Craniopharyngioma - Postop,Hematology - Oncology,"hematology - oncology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,"
Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.,"PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.  The patient states that he had his first colonoscopy 6 years ago and it was negative.  His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86.  The patient does have hemorrhoidal bleed about once a week.  Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss.  He gets heartburn mainly with certain food such as raw onions and he has had it for years.  It will typically occur every couple of weeks.  He has had no dysphagia.  He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS:  ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired.  He is married.  He had 4 children.  He quite smoking 25 years ago after a 35-year history of smoking.  He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s.  Her mother smoked and drank.  Father got a mesothelioma at age 65.  There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy.  He has some increased urinary frequency from a history of prostatitis.  He has the heartburn, which is diet dependent and the frequent rectal bleeding.  He also has restless legs syndrome at night.  No cardio or pulmonary complaints.  No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress.  BP 112/70.  Pulse 80 and regular.  Respirations non-labored.  Height 5 feet 7-1/2 inches.  Weight 209 pounds.  HEENT exam:  Sclerae are anicteric.  Pupils equal, conjunctivae clear.  No gross oropharyngeal lesions.  Neck is supple without lymphadenopathy, thyromegaly, or JVD.  Lungs are clear to percussion and auscultation.  Heart sounds are regular without murmur, gallop, or rub.  The abdomen is soft and nontender.  There are no masses.  There is no hepatosplenomegaly.  The bowel sounds are normal.  Rectal examination:  Deferred.  Extremities have no clubbing, cyanosis or edema.  Skin is warm and dry.  The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1.  Family history of colon cancer.,2.  Rectal bleeding.,3.  Heartburn and a family history of esophageal cancer.,PLAN:,  I agree with the indications for repeat colonoscopy, which should be done at least every 5 years.  Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable.  I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus.  If he does not have it now then it should not be a significant risk in the future.  The indications and benefits of EGD, colonoscopy, and IRC were discussed.  The risks including sedation, bleeding, infection, and perforation were discussed.  The importance of a good bowel prep so as to minimize missing any lesions was discussed.  His questions were answered and informed consent obtained.  It was a pleasure to care for this nice patient.",Consult - Rectal Bleeding,Gastroenterology,"gastroenterology, heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer,"
"Dysphagia, possible stricture.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.","PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.",Gastroscopy - 1,Gastroenterology,gastroenterology
Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.",Bilateral Carotid Cerebral Angiogram,Neurosurgery,"neurosurgery, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
MRI Cervical Spine without contrast.,"EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.",MRI Cervical Spine - 2,Neurology,"neurology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord"
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.,"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",Supraclavicular Lymphadenopathy,Cardiovascular / Pulmonary,
"Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.","PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.",Anterior Cervical Discectomy & Arthrodesis - 1,Orthopedic,"orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,"
This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.,"TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1.  AWAKE:  Normal.,2.  SLEEP:  No activation.,3.  CLINICAL EVENTS:  None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed.  The waking background is unchanged from that previously reported.  Hyperventilation produced no changes in the resting record.  Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained.  Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is normal video EEG monitoring for a patient of this age.  No interictal epileptiform activity was identified.  The patient had no clinical events during the recording.  Clinical correlation is required.",Video EEG,Neurology,"neurology, electroencephalography, eeg monitoring, video eeg, seizures, eeg,"
"Esophagogastroduodenoscopy, patient with dysphagia.","PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,",EGD - 2,Gastroenterology,"gastroenterology, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia"
"The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.","SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.",SOAP - Shortness of Breath,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,"
MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.,"CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.",MRI C-Spine - C5-6 Disk Herniation,Orthopedic,"orthopedic, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,"
Left arm and hand numbness.  CT head without contrast.  Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,"REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.",CT Head - 3,Neurology,"neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm,"
Flexible Bronchoscopy (pediatric),"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.",Bronchoscopy - Pediatric,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"The patient is 14 months old, comes in with a chief complaint of difficulty breathing.","HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.",Difficulty Breathing - ER Visit,Cardiovascular / Pulmonary,
Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.,"REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Colon Polyps - Genetic Counseling,Gastroenterology,"gastroenterology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,"
Patient returns for his first followup after shunt surgery.,"REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, ""I feel like I can have a normal conversation with him again.""  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.",First Followup - Shunt Surgery,Neurosurgery,
"Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.","PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.",Cardiac Catheterization - 8,Cardiovascular / Pulmonary,
"Still having diarrhea, decreased appetite.","SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.",Clostridium Difficile Colitis Followup,Gastroenterology,"gastroenterology, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,"
Patient with a past medical history of a left L5-S1 lumbar microdiskectomy with complete resolution of left leg symptoms.,"HISTORY:,  The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle.  Symptoms are worsened by any activity and relieved by rest.  He also feels that when the pain is very severe, he has some subtle right leg weakness.  No left leg symptoms.  No bowel or bladder changes.,On brief examination, full strength in both lower extremities.  No sensory abnormalities.  Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles.  Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:,  Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities.  The right common peroneal F-wave is minimally prolonged.  The right tibial H reflex is absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle.  It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles.  There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals an acute right S1 radiculopathy.  There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future.",EMG/Nerve Conduction Study - 6,Neurology,"neurology, microdiskectomy, needle emg, nerve conduction studies, lumbosacral paraspinal muscles, lumbar microdiskectomy, lower extremities, lumbosacral paraspinal, paraspinal muscles, gluteus maximus, leg symptoms, gastrocnemius medialis, emg/nerve, conduction, lumbosacral, needle, gastrocnemius, medialis, muscles,"
Sleep study - patient with symptoms of obstructive sleep apnea with snoring.,"PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.",Sleep Study Interpretation,Neurology,"neurology, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index,"
"Acute renal failure, suspected, likely due to multi-organ system failure syndrome.","REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.",Renal Failure - Consult,Nephrology,
"Left neck dissection.   Metastatic papillary cancer, left neck.  The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.","PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.",Neck Dissection,Hematology - Oncology,"hematology - oncology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer"
MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",MRI Brain - SLE & Stroke,Radiology,
"The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.","REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.",Pericardial Effusion,Cardiovascular / Pulmonary,
"Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.","INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.",Radionuclide Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia"
"Left heart catheterization, left ventriculography, selective coronary angiography.","PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.","Heart Catheterization, Ventriculography, & Angiography - 9",Cardiovascular / Pulmonary,
"Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.","PROCEDURE:,  Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.  This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,PROCEDURE DETAILS:,  The patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained.  Right groin was prepped and draped sterilely and infiltrated 2% Xylocaine.  Using the Seldinger technique, a #6-French sheath was placed in the right femoral artery.  ACT was checked and was low.  Additional heparin was given.  A #6-French pigtail catheter was passed.  Left ventriculography was performed.  The catheter was exchanged for a #6-French JL4 catheter.  Nitroglycerin was given in the left main.  Left coronary angiography was performed.  The catheter was exchanged for a #6-French __________ coronary catheter.  Nitroglycerin was given in the right main, and right coronary angiography was performed.  Films were closely reviewed, and it was felt that he had a significant lesion in the RCA and the distal left circumflex is basically an OM.  Considering his age and his course, it was elected to stent both these lesions.  ReoPro was started, and the catheter was exchanged for a #6-French JR4 guide.  ReoPro was given in the RCA to prevent no reflow.  A 0.014 Universal wire was passed.  The lesion was measured.  A 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result.  The catheter was removed and exchanged for a #6-French JL4 guide.  The same wire was passed down the circumflex and the lesion measured.  A 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result.  Plavix was given.  The catheter was removed and sheath was in place.  The results were explained to the patient and his wife.,FINDINGS,1.  Hemodynamics.  Please  see attached sheet for details.  ED was 20.  There is no gradient across the aortic valve.,2.  Left ventriculography revealed septum upper limits of normal size with borderline normal LV systolic function with borderline normal wall motion, in which there is a question of  diffuse, very minimal global hypokinesis.  There is mild MR noted.,3.  Coronary angiography.,a.  Left main normal.,b.  LAD.  Some very minimal luminal irregularities.  There is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c.  Left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d.  The RCA is large dominant and has a mid somewhat long 70% lesion.,4.  Stenting.,a.  The RCA revealed a lesion that went from 70% to a -5%.,B.  The circumflex went from 95% to -5%.,CONCLUSION,1.  Decreased left ventricular compliance.,2.  Borderline normal overall ejection fraction with mild mitral regurgitation.,3.  Triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4.  Successful stenting of the right coronary artery and the circumflex.,RECOMMENDATION: , ReoPro/stent protocol, Plavix for at least 9 months, aggressive control of risk factors.  I have ordered Zocor and a fasting lipid panel.,AICD will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.","Heart Catheterization, Ventriculography, & Angiography - 14",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex,"
Right heart catheterization.   Refractory CHF to maximum medical therapy.,"PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.",Heart Catheterization - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy"
"Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location.","PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.",Esophagoscopy & Foreign Body Removal,Gastroenterology,"gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,"
Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis.,"HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.",ENT Consult,ENT - Otolaryngology,
A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,"PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.",Mantle Cell Lymphoma,Hematology - Oncology,
Coronary Artery CTA with Calcium Scoring and Cardiac Function,"EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.",Coronary CT Angiography (CCTA) - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography,"
"Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.","PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.",Biceps Tendon Repair,Orthopedic,"orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,"
Pulmonary Function Test to evaluate dyspnea.,"HISTORY:,  Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:,  FVC was 59%.  FEV1 was 61%.  FEV1/FVC ratio was 72%. The predicted was 70%.  The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  SVC was 69%. Inspiratory capacity was 71%.  Expiratory residual volume was 61%.  The TGV was 94%.  Residual volume was 113% of its predicted.  Total lung capacity was 83%.  Diffusion capacity was diminished.,IMPRESSION:,1.  Moderate restrictive lung disease.,2.  Some reversible small airway obstruction with improvement with bronchodilator.,3.  Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4.  Flow volume loop was consistent with the above and no upper airway obstruction.,",Pulmonary Function Test - 0,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lung, capacity"
"Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.","CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.",Well-woman checkup,Obstetrics / Gynecology,
Laparoscopic appendectomy and peritoneal toilet and photos.  Pelvic inflammatory disease and periappendicitis.,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic inflammatory disease.,2.  Periappendicitis.,PROCEDURE PERFORMED:,1.  Laparoscopic appendectomy.,2.  Peritoneal toilet and photos.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS FOR PROCEDURE: , The patient is a 31-year-old African-American female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  She also had mild leukocytosis with bright blood cell count of 12,000.  The necessity for diagnostic laparoscopy was explained and possible appendectomy.  The patient is agreeable to proceed and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department.,The preoperative Foley, antibiotics, and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation.  At this point, the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  With the aid of a laparoscope, the pelvis was visualized.  The ovaries are brought in views and photos are taken.  There is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  Attention was then turned on the right lower quadrant.  The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears.  Attention was turned to the suprapubic area.  The 12 mm port was introduced under direct visualization and the mesoappendix was identified.  A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  Next, ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  Next, attention was turned to the right upper quadrant.  There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz-Hugh-Curtis syndrome also a prior pelvic inflammatory disease.  All free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  Once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 Vicryl suture on a UR-6 needle.  Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and #4-0 Vicryl subcuticular closure is performed with undyed Vicryl.  Steri-Strips are applied along with sterile dressings.  The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum IV antibiotics in the General Medical Floor.  Routine postoperative care will be continued on this patient.",Appendectomy - Laparoscopic,Gastroenterology,"gastroenterology, acute appendicitis, periappendicitis, peritoneal toilet, pelvic inflammatory disease, abdominal wall, direct visualization, toilet, appendectomy, mesoappendix, laparoscopic, port, inflammatory"
One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes.,"She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.",Decreased Vision Consult,Ophthalmology,"ophthalmology, cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision,"
Patient presents with complaint of lump in the upper outer quadrant of the right breast,"CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.",Consult - Breast Cancer,Hematology - Oncology,
"Total knee replacement.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.","PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.",Total Knee Replacement - 1,Orthopedic,"orthopedic, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee,"
"Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.","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.",Thoracoscopy & Thoracotomy - Mesothelioma,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy,"
Plastic piece foreign body in the right main stem bronchus.  Rigid bronchoscopy with foreign body removal.,"PREOPERATIVE DIAGNOSIS: , Foreign body in airway.,POSTOPERATIVE DIAGNOSIS:,  Plastic piece foreign body in the right main stem bronchus.,PROCEDURE: , Rigid bronchoscopy with foreign body removal.,INDICATIONS FOR PROCEDURE: , This patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  The patient had a chest x-ray and based on that there is concern by the Radiology it could be a foreign body in the right main stem.  The patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general mask anesthesia.  Using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  There were some secretions but that looked okay.  Got down at the level of the carina to see a foreign body flapping in the right main stem.  I then used graspers to grasp to try to pull into the scope itself.  I could not do that, I thus had to pull the scope out along with the foreign body that was held on to with a grasper.  It appeared to be consisting of some type of plastic piece that had broke off some different object.  I took the scope and put it back down into the airway again.  Again, there was secretion in the trachea that we suctioned out.  We looked down into the right bronchus intermedius.  There was no other pathology noted, just some irritation in the right main stem area.  I looked down the left main stem as well and that looked okay as well.  I then withdrew the scope.  Trachea looked fine as well as the cords.  I put the patient back on mask oxygen to wake the patient up.  The patient tolerated the procedure well.",Bronchoscopy & Foreign Body Removal,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, main stem bronchus, bronchoscopy, airway, foreign body removal, rigid bronchoscopy,"
The patient underwent a total vaginal hysterectomy.,"ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.",Hysterectomy - Discharge Summary,Obstetrics / Gynecology,"obstetrics / gynecology, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy,"
Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram.,"PREOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1.  Carotid artery occlusive disease.,2.  Peripheral vascular disease.,OPERATIONS PERFORMED:,1.  Bilateral carotid cerebral angiogram.,2.  Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized.  The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized.  The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance.  A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed.  Heparin had been initially given, which was reversed with protamine.  Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.",Bilateral Carotid Cerebral Angiogram,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,"
"The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.","HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  He also has VACTERL association with hydrocephalus.  As an infant, he underwent placement of a right modified central shunt.  On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt.  On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization.  He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units.  On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion.  The patient then followed conservatively since that time.  The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:,  After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  This catheter was then exchanged for a 5-French VS catheter of a distal wire.  Apposition of the right pulmonary artery over, which the wedge catheter was advanced.  The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  Left ventricular pressure was found to be suprasystemic.  A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium.  There was a disappearance of a mild waist prior to spontaneous tear of the balloon.  The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  Further attempts to cross tricuspid valve were thus abandoned.  Attention was then directed to a Fontan fenestration.  A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg.  With less than 10% fall in calculated cardiac index.  The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  A 7-French flexor sheath was again advanced cross the fenestration.  A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  Once the stable device configuration was confirmed, device was released from the delivery catheter.  Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to systemic arterial desaturation.  There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  The right pulmonary veins were fully saturated.  Left pulmonary veins were not entered.  There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration.  Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery.  Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg.  Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta.  Phasic ascending and descending aortic pressures were similar and normal.  The calculated systemic flow was normal.  Pulmonary flow was reduced to the QT-QS ratio of 0.7621.  Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis.  There was symmetric contrast flow to both pulmonary arteries.  A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration.  There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  The branch pulmonaries appeared mildly hypoplastic.  Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava.  Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  There was an increase in the systemic arterial pressures.  Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921.  Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow.  An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  A small degree of contrast returned to the heart.,INITIAL DIAGNOSES:  ,1.  Pulmonary atresia.,2.  VACTERL association.,3.  Persistent sinusoidal right ventricle to the coronary communications.,4.  Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Systemic to pulmonary shunts.,2.  Right bidirectional Glenn shunt.,3.  Revision of the central shunt.,4.  Ligation and division of patent ductus arteriosus.,5.  Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES:  ,1.  Favorable Fontan hemodynamics.,2.  Hypertensive right ventricle.,3.  Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  Patent Fontan fenestration.,CURRENT INTERVENTION:  ,1.  Balloon dilation tricuspid valve attempted and failed.,2.  Occlusion of a Fontan fenestration.,MANAGEMENT:  ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  Further cardiologic care will be directed by Dr. X.",Pulmonary Atresia,Cardiovascular / Pulmonary,
"To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.","CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.",Cardiac Consultation - 1,Cardiovascular / Pulmonary,
Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,"PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",Anterior Cervical Discectomy & Fusion - 2,Orthopedic,
"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.","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.",C. Diff Colitis Consult,Gastroenterology,
Direct current cardioversion.  Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.,"PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits including risk of stroke.  The patient understands as well as her husband.  The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium.  There was spontaneous echocardiogram contrast noticed.  The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed.  The pads applied in the anterior and posterior approach.  With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm.  The patient had some occasional PACs noticed with occasional sinus tachycardia.  The patient had no immediate post-procedure complications.  The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION:  ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.",Cardioversion - Direct Current,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion"
"Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.","PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,",Hysterectomy & Salpingoophorectomy,Obstetrics / Gynecology,
Polycythemia rubra vera.  The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.,"CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Polycythemia Rubra Vera,Hematology - Oncology,"hematology - oncology, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,"
"Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.","REASON FOR NEUROLOGICAL CONSULTATION:,  Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  More recently, he describes a burning sensation along with numbness.  This has become a particular problem and of all the problems he has he feels that pain is his primary concern.  Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  He denies any weakness per se, just clumsiness and decreased sensation.  He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  This has been a fairly longstanding problem, and again has become more prevalent recently.  He does not have any tremor.  He denies any neck pain.  He walks with the aid of a walker because of unsteadiness with gait.,Recently, he has tried gabapentin, but this was not effective for pain control.  Oxycodone helps somewhat and gives him at least three hours pain relief.  Because of the pain, he has significant problems with fractured sleep.  He states he has not had a good night's sleep in many years.  About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility.  At that facility, his insulin was stopped.  Since then he has only been on oral medication for his diabetes.  He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,PAST MEDICAL HISTORY: , Diabetes, hypertension, coronary artery disease, stroke, arthritis, GERD, and headaches.,MEDICATIONS: , Trazodone, simvastatin, hydrochlorothiazide, Prevacid, lisinopril, glipizide, and gabapentin.,FAMILY HISTORY: , Discussed above and documented on the chart.,SOCIAL HISTORY: , Discussed above and documented on the chart.  He does not smoke.  He lives in a senior citizens building with daily nursing aids.  He previously was a security guard, but is currently on disability.,REVIEW OF SYSTEMS: , Discussed above and documented on the chart.,PHYSICAL EXAMINATION: , On examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  Pain scale 7/10.  A full general and neurological examination was performed on the patient and is documented on the chart.,The patient is obese with significant ankle edema.,Neurological examination reveals normal cognitive exam and normal cranial nerve examination.  Motor examination reveals mild atrophy in bilateral FDIs, but still has a strong grip.  Individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  Tone and bulk are normal.  Sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  He has no vibration sense at his knees.  Similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  The only reflexes I could obtain with trace reflexes in his biceps.  Remaining reflexes were unelicitable.  No Babinski.  The patient walks normally with the aid of a cane.  He has severe sensory ataxia with inability to walk unaided.  Positive Romberg with eyes open and closed.,IMPRESSION AND PLAN:,1.  Probable painful diabetic neuropathy.  Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  He has relative preservation of motor function.  Because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, I would like to rule out other causes of progressive neuropathy.,2.  He has history of myoclonic jerks.  I did not see any on my examination today and I feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  I would like to rule out other causes such as hepatic encephalopathy., ,I have recommended the following:,1.  EMG/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  Blood work, looking for other causes of neuropathy and myoclonus, to include CBC, CMP, TSH, LFT, B12, RPR, ESR, Lyme titer, and HbA1c, and ammonia level.,3.  Neurontin and oxycodone have not been effective, and I have recommended Cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  Side effect profile of this medication was discussed with the patient.,4.  I have explained to him that progression of diabetic neuropathy is closely related to diabetic control and I have recommended tight diabetic control.,5.  I will see him at followup at the EMG.",Neurologic Consultation - 4,Neurology,
Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.,"XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,",Anaplastic Astrocytoma - Letter,Neurology,"neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma"
"A nurse with a history of breast cancer enrolled is clinical trial C40502.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.","CHIEF COMPLAINT:,1.  Metastatic breast cancer.,2.  Enrolled is clinical trial C40502.,3.  Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer.  She was initially diagnosed in June 1994.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.  PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502.  She was randomized to the ixabepilone plus Avastin.  She experienced dose-limiting toxicity with the fourth cycle.  The Ixempra was skipped on day 1 and day 8.  She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  Early in the month she had concerned about possible perforated septum.  She was seen by ENT urgently.  She was found to have nasal septum intact.  She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS:  ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES:  ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation.  She has progressive neuropathy and decreased sensation in her fingertips.  She makes many errors when keyboarding.  I would rate her neuropathy as grade 2.  She continues to have headaches respond to Ultram which she takes as needed.  She occasionally reports pain in her right upper quadrant as well as right sternum.  He denies any fevers, chills, or night sweats.  Her diarrhea has finally resolved and her bowels are back to normal.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Breast Cancer Followup,Hematology - Oncology,"hematology - oncology, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer,"
"Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.","TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.",Septal Defect Repair,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary,"
Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.,"PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.",Heart Cath & Coronary Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,"
"Severe back pain and sleepiness.  The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.","CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain.  As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection.  The patient has severe pain and all in all, the patient cries at home.  As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation.  The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria.  While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control.  The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli.  The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked.  The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.,PAST MEDICAL CONDITIONS:,  Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine.  No history of diabetes, stroke or coronary artery disease.,SURGICAL HISTORY: , Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.,ALLERGIES: , DENIED.,CURRENT MEDICATIONS: , According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day.  The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.,SOCIAL HISTORY: , She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows.  No history of alcohol abuse or smoking.,PHYSICAL EXAMINATION:,GENERAL:  Currently lying in the bed without apparent distress, very lethargic.,VITAL SIGNS:  Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.,CHEST:  Shows bilateral air entry present, clear to auscultate.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft, nondistended, and nontender.,EXTREMITIES:  Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.,IMAGING: , The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.,LABORATORY DATA: , The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.,IMPRESSION: , The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.,1.  Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.,2.  Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.,3.  Hypertension, now hypotension.,4.  Incontinence of the bladder.,5.  Dementia, most likely Alzheimer type.,PLAN AND SUGGESTION: , Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept.  I will hold the patient's hydrocodone.  I will hold the Flexeril and I will also hold gabapentin at this moment.  We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed.  Also give the patient calcium with vitamin D and physical therapy.  We will also order a blood test and further management will be based on the patient's all test results.  I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.",Sleepiness - Consult,Neurology,
Decreased ability to perform daily living activities secondary to right knee surgery.,"CHIEF COMPLAINT:,  Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007.  The patient was transfused with 2 units of autologous blood postoperatively.  She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings.  The remainder of her postoperative course was uneventful.  She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation.  The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital.  She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties.  She reports having some right knee pain, which is most intense at a ""certain position.""  The patient is unable to elaborate on which ""certain position"" causes her the most discomfort.,ALLERGIES:,  NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:,  On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of the exam except as mentioned above complains of right knee pain at ""certain position."",HEENT:  Normocephalic.  Sclerae nonicteric.  EOMI.  Dentition in good repair.  Tongue is in midline with no evidence of thrush.,NECK:  No thyroid enlargement.  Trachea is midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Soft, nontender, and nondistended.  No organomegaly.,EXTREMITIES:  The right knee incision is intact.  Steri-Strips are in place.  There is some diffuse right knee edema and some limited ecchymosis as well.  No calf tenderness bilaterally.  Pedal pulses are palpable bilaterally.,MENTAL STATUS:  The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation.  She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery.  The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours.  Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain.  She remarked that she had a better degree of flexibility, but she did report an increased need for pain management.  Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder.  On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen.  The patient reported that this rash was itchy.  She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively.  She was treated with betamethasone cream applied to the rash b.i.d.  The patient's therapy had progressed and she continued to make a good progress.  At one point, the patient reported some insomnia due to right knee pain.  She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain.  The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range.  The Coumadin was adjusted accordingly according to the INRs during her hospital course.  Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally.  Initial laboratory data includes a UA on 08/28/2007, which was negative.  Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000.  Chemistries were within normal limits.  Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102.  The remainder of chemistries was unremarkable.  The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1.  Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2.  Anxiety disorder.,3.  Insomnia secondary to pain and anxiety postoperatively.,4.  Postoperative constipation.,5.  Contact dermatitis secondary to preoperative gardening activities.,6.  Hypertension.,7.  Hypothyroidism.,8.  Gastroesophageal reflux disease.,9.  Morton neuroma of the feet bilaterally.,10.  Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications:  Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily.  The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926.  At the present time, the patient is taking Coumadin 7 mg daily.  She will remain on Coumadin for 30 days.  An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary.  Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office.  The patient is encouraged to follow up with her primary care physician, Dr. B.  As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.",Knee Surgery - Discharge Summary,Orthopedic,
CT of Brain - Subacute SDH.,"CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.",CT Brain: Subdural hematoma,Neurology,"neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,"
Flexible Bronchoscopy (pediatric),"FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.",Bronchoscopy - Pediatric,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.","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.,",Thoracentesis - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural,"
MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.,"CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:,  BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was ""moderately severely"" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a ""curtain"" came down over both visual fields, like ""everything was in the shade."" During the episode he felt fully alert and aware of his surroundings. He concurrently heard a ""grating sound"" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly ""normal"" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.",Alzheimer Disease,Neurology,"neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory,"
Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,"TITLE OF OPERATION:,  Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache.  All endocrine labs were normal.  Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:,  Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended.  The patient was then prepped and draped in the usual sterile fashion.  With the assistance of fluoro and mapping the localization, the right nostril was infiltrated.  Dr. X will dictate the procedure of the approach.  Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling.  Once the operating microscope was in the field, at this point, the drilling was completed.  The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor.  This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down.  Once this was completed, there was no evidence of any bleeding.  The endoscope was then used to remove any residual fragments __________ with the arachnoid.  Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X.  She was reversed, extubated, and transported to the ICU in stable condition.  Blood loss, minimal.  All sponge, needle counts were correct.",Cystic Suprasellar Tumor Resection,Neurosurgery,"neurosurgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor,"
"Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.","REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.",Preeclampsia,Cardiovascular / Pulmonary,
"Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.","PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.",Bronchoscopy - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,"
CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.,"EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.",CT of Chest with Contrast,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest"
Left lower extremity venous Doppler ultrasound,"LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.",Lower Extremity Venous Doppler,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,"
Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation,"HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.",Cardioversion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,"
"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.","Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.",Cardiovascular - Letter,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin"
"Carpal tunnel release with transverse carpal ligament reconstruction.  A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.","PROCEDURE:,  Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.",Carpal Ligament Reconstruction,Orthopedic,"orthopedic, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal"
HDR Brachytherapy,"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.",HDR Brachytherapy,Hematology - Oncology,"hematology - oncology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.","DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:,  Colonoscopy.,FINDINGS:,  Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood.  Dr. Y Miller saw him in consultation and recommended a colonoscopy.  A bowel prep was done.  H&Hs were stable.  His most recent H&H was 38.6/13.2 that was this morning.  His H&H at admission was 41/14.3.  The patient had the bowel prep that revealed no significant bleeding.  His vital signs are stable.  He is continuing on his usual medications of Imdur, metoprolol, and Synthroid.  His Plavix is discontinued.  He is given IV Protonix.  I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8.  Chemistry panel was unremarkable.  The patient was given a regular diet after his colonoscopy today.  He tolerated it well and is being discharged home.  He will be followed closely as an outpatient.  He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission.  He will hold his Plavix for now.  They will call me for further dark stools and will avoid Pepto-Bismol.  They will follow up in the office on Thursday.",Gastrointestinal Bleed - Discharge Summary,Gastroenterology,"gastroenterology, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep"
"Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.","REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.",Cervical Spinal Stenosis,Neurology,
Consult and Spinal fluid evaluation in a 15-day-old,"HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.",Spinal fluid evaluation,Pediatrics - Neonatal,
A 10 years of age carries a diagnosis of cystic fibrosis,"INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.",Cystic Fibrosis,Cardiovascular / Pulmonary,
"Left heart catheterization with ventriculography, selective coronary angiography.  Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.","NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.  ,ANTICOAGULATION:  ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery.  All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA:  ,Aortic pressure was in the physiologic range.  No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram:  The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery:  Dominant.  There was insignificant disease in the system.,3. Left coronary:  Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted.  Six-French Angio-Seal was used in the groin.","Heart Catheterization, Ventriculography, & Angiography - 4",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,"
"A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.","CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.",Infant Not Gaining Weight,Pediatrics - Neonatal,
"Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.","PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.",Foreign Body Removal - Foot - 1,Orthopedic,"orthopedic, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,"
Brain CT and MRI - suprasellar mass (pituitary adenoma),"CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).",Brain MRI - Pituitary Adenoma,Neurology,"neurology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar,"
Holter monitoring for syncope.  Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.,"INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  No significant pauses noted.",Holter Monitor Report - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE"
Right pleural effusion and suspected malignant mesothelioma.,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.",Mesothelioma - Pleural Biopsy,Hematology - Oncology,"hematology - oncology, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,"
"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.","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.",Thrombectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,"
Bronchoscopy with aspiration and left upper lobectomy.  Carcinoma of the left upper lobe.,"PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1.  Bronchoscopy with aspiration.,2.  Left upper lobectomy.,PROCEDURE DETAILS:  ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  The carina was in the midline and sharp.  Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  Aspiration was carried out for backlog ________ examination.  We then moved to left side, left upper lobe.  There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  No anatomic lesions were demonstrated.  The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter.  After proper position, utilizing Betadine solution, they were draped.  A posterolateral left thoracotomy incision was performed.  Hemostasis was secured with electrocoagulation.  The chest wall muscle was then divided over the sixth rib.  The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  We examined the superior mediastinum.  No lymph nodes were demonstrated as well as in the anterior mediastinum.  Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  Tumor mass was close to the artery at this time.  We then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  The posterior artery of the superior branch was doubly ligated and cut free also.  At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  The anterior artery was seen in the clamp also and was separated and ligated and separated.  At this time, the entire tumor in the left upper lobe was then removed.  ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  The clamp was then removed.  No bleeding was seen at this time.  Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  The chest cavity was then closed.  After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time.  The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.",Bronchoscopy & Lobectomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,"
Coronary Artery CTA with Calcium Scoring and Cardiac Function,"EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.",Coronary CT Angiography (CCTA) - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography,"
"Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.","PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.",Decompressive Laminectomy,Neurosurgery,"neurosurgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,"
Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.,"DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.",EEG,Neurology,"neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE"
"Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.","DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.",Vitrectomy - 3,Ophthalmology,"ophthalmology, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE"
"Tilt table test.  Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.","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.",Tilt Table Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE"
"Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.","PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.",de Quervain Release - Carpal,Orthopedic,"orthopedic, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,"
Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,POSTOPERATIVE DIAGNOSIS: , Right pleural effusion with respiratory failure and dyspnea.,PROCEDURE: , Ultrasound-guided right pleurocentesis.,ANESTHESIA: , Local with lidocaine.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound.  Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right.  Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L.  The patient tolerated the procedure well.  Portable x-ray is pending.",Pleurocentesis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,"
Spontaneous controlled sterile vaginal delivery performed without episiotomy.,"The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to ""labor down"" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.",Delivery Note - 1,Obstetrics / Gynecology,"obstetrics / gynecology, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter.,"PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.",Broviac Catheter Placement,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,"
"Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.  Removal of antibiotic spacer and revision total hip arthroplasty.","PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.",Total Hip Arthroplasty - Revision,Orthopedic,"orthopedic, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur,"
"Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.","REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you.",Renal Insufficiency - Consult,Nephrology,
"Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.","PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.",Arthroscopic SLAP lesion,Orthopedic,"orthopedic, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff"
Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.,"REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Colon Polyps - Genetic Counseling,Hematology - Oncology,"hematology - oncology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,"
Cardiolite treadmill exercise stress test.  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.,"CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.",Cardiolite Treadmill Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,"
Epigastric herniorrhaphy.  Epigastric hernia.,"PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.",Epigastric Herniorrhaphy,Gastroenterology,"gastroenterology, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,"
"Clogged AV shunt.  The patient complains of fatigue, nausea, vomiting and fever.","REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read ""did not work"".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.",Clogged AV Shunt - Consult,Nephrology,
"New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.","REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.",Non-Small Cell Lung Cancer - Consult,Hematology - Oncology,
"Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.","PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.",Microlaryngoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,"
"Severe tonsillitis, palatal cellulitis, and inability to swallow.","CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",Exudative Tonsillitis,ENT - Otolaryngology,
Left heart cardiac catheterization.,"PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.",Cardiac Catheterization - 9,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending"
A sample note on pre-eclampsia & eclampsia.,"PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised.  It usually occurs from the 20th week of pregnancy to 7 days postpartum.  The cause is unknown.  It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process.  The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years.  There are identifiable risk factors for developing pre-eclampsia:  family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy).  A chronic high blood pressure and underlying blood vessel disease increases the risk.  Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage.  Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,*  Significant blood pressure increase even if you are still within the normal blood pressure limits.,*  Swelling in the face, hands and feet which worsens in the a.m.,*  Gaining more than a pound a week, especially in the last trimester.,*  Routine prenatal checkup reveals protein in the urine.,*  Seizures are possible.,SEVERE PRE-ECLAMPSIA:,*  More blood pressure increase.,*  Further swelling in face, hands and feet.,*  Visual disturbances.,*  Headache.,*  Irritability.,*  Abdominal pain.,*  Tiredness.,*  Decreased urination.,*  Seizures possible.,*  Nausea and vomiting.,ECLAMPSIA:,*  Symptoms worsen.,*  Seizures.,*  Muscle twitches.,*  Coma.,TREATMENT:,*  Diagnosis - blood tests, urinalysis, blood pressure monitoring.,*  Mild preeclampsia can be treated at home.  Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,*  Daily weighing.,*  Daily monitoring for protein in urine.,*  Medications to lower blood pressure if preeclampsia is severe.,*  Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,*  Get lots of rest! Lay on your left side to help circulation.,*  Follow any dietary advice given by your doctor.,*  Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,*  Never take any medications that are not prescribed or recommended by your physician.,*  Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda.  In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration.  For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.",Pre-Eclampsia & Eclampsia,Obstetrics / Gynecology,
Pediatric Gastroenterology - Rectal Bleeding Consult.,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",Rectal Bleeding - 1-year-old,Gastroenterology,
She is sent for evaluation of ocular manifestations of systemic connective tissue disorders.  Denies any eye problems and history includes myopia with astigmatism.,"Her past medical history includes a presumed diagnosis of connective tissue disorder.  She has otherwise, good health.  She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically.  She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD.  She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS.  Intraocular pressures are 13 OU and by applanation.  Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  Gonioscopy showed normal anterior segment angle morphology in both eyes.  She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes.  Conjunctivae were quite, OU.  Cornea were clear in both eyes.  The anterior chamber is deep and quiet, OU.  She has clear lenses, which are in good position, OU.  Dilated fundus exam shows moderately optically clear vitreous, OU.  The optic nerves are normal in size.  The cup-to-disc ratios were approximately 0.4, OU.  The nerve fiber layers are excellent, OU.  The macula, vessels, and periphery were normal in both eyes.  No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous.  She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  Otherwise, I can see her in 1 to 2 years.",Connective Tissue Disorder,Ophthalmology,"ophthalmology, systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes"
"Phacoemulsification of cataract, extraocular lens implant in left eye.","PREOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:,  Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:,  1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40.  The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery.  All questions from the patient were answered after the surgical procedure was explained in detail.  The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc.  Alternative of the procedure is to do nothing or seek a second opinion.  Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area.  Previously, an intravenous infusion was begun at a keep vein open rate.  After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye.  A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine.  An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area.  Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted.  Vital sign monitors were detached from the patient.  The patient was moved to the operative suite and the same monitors were reattached.  The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery.  The speculum was set into place and the operative microscope was brought over the eye.  The eye was examined.  Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea.  Then a pocket incision was created without entering the anterior chamber of the eye.  Two peripheral paracentesis ports were created on each side of the initial incision site.  Viscoelastic was used to deepen the anterior chamber of the eye.  A 2.65 mm keratome was then used to complete the corneal valve incision.  A cystitome was bent and created using a tuberculin syringe needle.  It was placed in the anterior chamber of the eye.  A continuous curvilinear capsulorrhexis was begun.  It was completed using O'Gawa Utrata forceps.  A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus.  The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye.  The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique.  All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports.  The posterior capsule remained intact throughout the entire procedure.  Provisc was used to deepen the anterior chamber of the eye.  A crescent blade was used to expand the internal aspect of the wound.  The lens was taken from its container and inspected.  No defects were found.  The lens power selected was compared with the surgery worksheet from Dr. X's office.  The lens was placed in an inserter under Provisc.  It was placed through the wound, into the capsular bag and extruded gently from the inserter.  It was noted to be adequately centered in the capsular bag using a Sinskey hook.  The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique.  The eye was noted to be inflated without overinflation.  The wounds were tested for leaks, none were found.  Five drops dilute Betadine solution was placed over the eye.  The eye was irrigated.  The speculum was removed.  The drapes were removed.  The periocular area was cleaned and dried.  Maxitrol ophthalmic ointment was placed into the interpalpebral space.  A semi-pressure patch and shield was placed over the eye.  The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.",Phacoemulsification of Cataract - 1,Ophthalmology,"ophthalmology, senile nuclear cataract, senile, phacoemulsification, phacoemulsification of cataract, lens implant, lens nucleus, anterior chamber, lens, alcon, eye, cataract,"
MRI right knee without gadolinium,"EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,",MRI Knee - 5,Orthopedic,"orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear"
Right hemothorax.  Insertion of a #32 French chest tube on the right hemithorax.  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion.,"PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.",Chest Tube Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma"
Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection.,"OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.",Mitral Valve Repair & Annuloplasty,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral,"
A sample note on RICE Therapy,"RICE, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,REST:,Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the hand, wrist, elbow, or arm. Continued exercise or activity could cause further injury, increased pain, or a delay in healing.,ICE:,Ice helps stop bleeding from injured blood vessels and capillaries. Sudden cold causes the small blood vessels to contract. This contraction decreases the amount of blood that can collect around the wound. The more blood that collects, the longer the healing time. Ice can be safely applied in many ways:,*  For injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. Use ice cubes to keep the water cold, adding more as the ice cubes dissolve.,*  For injuries to larger areas, use ice packs. Avoid placing the ice directly on the skin. Before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. To make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the cloth. The pack may sit directly on the injured part, or it may be wrapped in place.,*  Ice the injured area for about 30 minutes.,*  Remove the ice to allow the skin to warm for 15 minutes.,*  Reapply the ice.,*  Repeat the icing and warming cycles for 3 hours. Follow the instructions below for compression and elevation. If pain and swelling persist after 3 hours call our office. You may need to change the icing schedule after the first 3 hours. Regular ice treatment is often discontinued after 24 to 48 hours. At that point, heat is sometimes more comfortable.,COMPRESSION:,Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. Without compression, fluid from adjacent normal tissue seeps into the injured area. To apply compression safely to an injury:,*  Use an elasticized bandage (Ace bandage) for compression, if possible. If you do not have one available, any kind of cloth will suffice for a short time.,*  Wrap the injured part firmly, wrapping over the ice. Begin wrapping below the injury site and extend above the injury site.,*  Be careful not to compress the area so tightly that the blood supply is impaired. Signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. Remove the compression bandage immediately if any of theses symptoms appears. Leave the bandage off until all signs of impaired circulation disappear. Then rewrap the area--less tightly this time.,ELEVATION:,Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. Elevate the iced, compressed area in whatever way is most convenient. Prop an injured leg on a solid object or pillows. Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across.",RICE Therapy,Orthopedic,"orthopedic, rest, ice, compression, and elevation, foot, ankle, knee, leg, splints, hand, wrist, elbow, arm, ace bandage, compression and elevation, rice therapy, compression bandage, ice packs, rice, elevation, swelling, bandage, therapy"
Psychosocial donor evaluation.  Following questions are mostly involved in a psychosocial donor evaluation.,"PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A.  DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C.  MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume?  What drink do you prefer?,What kinds of recreational drugs have you tried?  Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live?  ,If you are in a relationship:,- length of the relationship:  ,- name of spouse/partner:  ,- age and health of spouse/partner:  ,- children:  ,E. POST-SURGICAL PLANS,With whom will you stay after discharge?  ,What is your current occupation:  ,Do you have the support of your employer?",Psychosocial Eval - Donor - 2,Psychiatry / Psychology,
"Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.   CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.","CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE:  ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS:  ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable.  No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.",CT Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue,"
Cerebral Angiogram - moyamoya disease.,"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",Moyamoya Disease,Radiology,
MRI for Arnold Chiari II with syrinx,"CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.",Arnold Chiari II with Syrinx,Neurology,"neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold"
"Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.","PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.",Open Plantar Fasciotomy,Orthopedic,"orthopedic, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot,"
"Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.","PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.",Delayed ORIF,Orthopedic,
Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.,"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.,",Transesophageal Echocardiography Probe,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe"
Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan.,"INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.",Adenosine Nuclear Scan,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,"
External cephalic version.  A 39-week intrauterine pregnancy with complete breech presentation.,"PREOPERATIVE DIAGNOSIS: , A 39-week intrauterine pregnancy with complete breech presentation.,POSTOPERATIVE DIAGNOSIS:,  A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,PROCEDURE: , External cephalic version.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained.  The patient was noted to have irregular contractions.  She was given 1 dose of subcutaneous terbutaline which resolved her contraction.  A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  There was noted to be adequate fluid.  Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  Following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  She did not have regular contractions and therefore she was felt to be stable for discharge to home.  She was given appropriate labor instructions.",External Cephalic Version,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine,"
"A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.","INTRODUCTION: , The opinions expressed in this report are those of the physician.  The opinions do not reflect the opinions of Evergreen Medical Panel, Inc.  The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I).  The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager.  The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:,  This patient was injured on November 20, 2008.  He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back.  The patient said he primarily landed on the left side.  After the accident he states that he was generally stun and someone at the institute advised him to be evaluated.  He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital.  At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan.  The patient describes that he had a brain CT and a dark spot was found.  It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma.  Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005.  The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments.  Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ.  She ordered an MRI of his neck.  Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS:  ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations:  He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications:  The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco:  He does not smoke cigarettes.,Alcohol:  He drinks about five beers a week.,FAMILY HISTORY:,  His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents:  The patient has been married three times; longest marriage is of two years duration.  He has two children.  These dependents are ages 15 and twins and are his wife's dependents.,Education:  The patient has bachelor's degree.,Military History:  He served six years in the army and received an honorable discharge.,Work History:  He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008.  He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain.  He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended.  He has a history of an old mastoidectomy.  He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008.  There is no clearcut history that he had lost consciousness.  He has a past history of removal of an acoustic neuroma in 2005 as noted.  A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma.  Some symptoms of loss of balance and confusion were noted.  She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008.  Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties.  It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard.  There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma.  He continued to have chiropractic adjustments.  He was seen back at Prompt Care on January 8, 2009.  Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain.  He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate.  Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ.  He felt that this was hyperextension cervical injury.  It might take a period of time to recover.  He mentioned that the patient might have a slight ulnar neuropathy.  He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination:  He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance.  Overall the patient is a seemingly good historian.  There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly.  These are secondary to drawing for the skull markers.  There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma.  This was well healed.  The patient can perform a toe-heel gait without difficulty.  One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering.  The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had.  The patient has a full range of motion in both of his shoulders.  The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees.  There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest.  He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction.  There is slight tenderness on palpating over the right cervical musculature.  There is no evidence of any cervical or lumbar muscle spasms.  Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis.  Knee jerks are 2+ and ankle jerks are 1+.  Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally.  The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally.  Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left.  Testing of muscle strength in the upper and lower extremities is normal.  The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally.  The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally.  The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm.  Pressure on the vertex of the head does not bother the patient.  Axial loading is negative.  As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space.  The hip joints are normal.  Views of his thoracic spine are normal.  Cervical x-rays are in the file.  These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc.  There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:,  The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan.  The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008.  Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine.  He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270.  His industrial case should be closed and there is, as indicated, no basis for any disability award.",IME & Record Review - Orthopedic,Orthopedic,
Patient with history of polyps.,"PREOPERATIVE DIAGNOSIS:,  Prior history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Small polyps, no evidence of residual or recurrent polyp in the cecum.,PREMEDICATIONS: , Versed 5 mg, Demerol 100 mg IV.,REPORTED PROCEDURE:,  The rectal chamber revealed no external lesions.  Prostate was normal in size and consistency.,The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  The position of the scope within the cecum was verified by identification of the ileocecal valve.  Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,The cecum was extensively studied and no lesion was seen.  There was not even a scar representing the prior polyp.  I was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and I saw no lesion at all.  The scope was then slowly withdrawn.  In the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  It was freely mobile and very small with normal overlying mucosa.  There was a similar lesion in the descending colon.  Both of these appeared to be lipomatous, so no attempt was made to remove them.  There were diverticula present in the sigmoid colon.  In addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  There was no bleeding.  The scope was then withdrawn.  The rectum was normal.  When the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  There was no specimen and there was no bleeding.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Small polyps, sigmoid colon, resected them.,2.  Diverticulosis, sigmoid colon.,3.  Small rectal polyps, obliterated them.,4.  Submucosal lesions, consistent with lipomata as described.,5.  No evidence of residual or recurrent neoplasm in the cecum.",Colonoscopy - 9,Gastroenterology,"gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,"
"Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.","PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,",Bronchoscopy - 9,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,"
Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.,"PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.",Endotracheal Intubation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma"
"Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.","PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.",Hypertension & Cardiomyopathy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,"
Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,"PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.",Fistulogram & Angioplasty,Cardiovascular / Pulmonary,
Vaginal discharge with a foul odor.,"CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,",Gardnerella Bacterial Vaginosis,Obstetrics / Gynecology,
"Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.","PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.","Laminotomy, Facetectomy & Foraminotomy",Orthopedic,"orthopedic, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle"
"Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.","PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.",Phacoemulsification & Lens Implantation - 1,Ophthalmology,"ophthalmology, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,"
"Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.","ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.",Pneumonia - Discharge Summary,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,"
The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.,"REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.",Consult - Normal Pressure Hydrocephalus,Neurology,
"Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.","REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:",Consult - Atrial Fibrillation - 2,Cardiovascular / Pulmonary,
Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,"PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.",Endotracheal Intubation - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE"
Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,"NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.","Heart Catheterization, Ventriculography, & Angiography - 19",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography"
Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to ""pop into place.""  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , 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:  Blood pressure 130/71",Feet & Hand Cramping,Neurology,
"Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.","PROCEDURE:,  Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed.  The patient received topical lidocaine by nebulization.  The flexible fiberoptic bronchoscope was introduced orally.  The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions.  I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe.  I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies.  Followup fluoroscopy was negative for pneumothorax.  I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions.  I performed a bronchial washing after the biopsies in the right upper lobe.  I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area.  All of these samples were sent for histology and cytology respectively.  Estimated blood loss was approximately 5 cc.  Good hemostasis was achieved.  The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well.  Her ASA score was 2.",Bronchoscopy - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
"Severe tonsillitis, palatal cellulitis, and inability to swallow.","CHIEF COMPLAINT:  ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse.  He was unable to swallow.  He complained to his parent.  He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar.  He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis.  A CT scan at ER did not show abscess.  He has not had airway compromise, but he has had difficulty swallowing.  He may have had a low-grade fever, but nothing marked at home.  His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis.  He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY:  ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight.  He is a sophomore at High School.,FAMILY HISTORY:  ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker.  Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT:  The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU:  Denies dysuria.,Orthopedic:  Denies joint pain, difficulty walking, etc.,Neuro:  Denies headache, blurry vision, etc.,Eyes:  Says vision is intact.,Lungs:  Denies shortness of breath, cough, etc.,Skin:  He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care.  Mildly itchy.  Mother has penicillin allergy.,Endocrine:  The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General:  This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4.  Voice is normal.  He is handling his secretions.  There is no stridor.,Vital Signs:  See vital signs in nurses notes.,Ears:  TM and EACs are normal.  External, normal.,Nose:  Opening clear.  External nose is normal.,Mouth:  Has bilateral marked exudates, tonsillitis, right greater than left.  Uvula is midline.  Tonsils are touching.  There is some redness of the right palatal area, but is not consistent with peritonsillar abscess.  Tongue is normal.  Dentition intact.  No mucosal lesions other than as noted.,Neck:  No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest:  Clear to auscultation.,Heart:  No murmurs, rubs, or gallops.,Abdomen:  Obese.  Complete exam deferred.,Skin:  Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro:  Cranial nerves II through XII are intact.  Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection.  No significant prior history of tonsillitis.  Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral.  I do not insist that this patient will need surgical intervention since there is no evidence of abscess.  This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient.  The patient's parents in the room had expressed good understanding, have a chance to ask questions.  At this time, I will see the patient back on an as needed basis.",Exudative Tonsillitis,ENT - Otolaryngology,
Thoracic right-sided discectomy at T8-T9.   The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.,"PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.  She has failed conservative measures and sought operative intervention for relief of her symptoms.  For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION:  ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic.  She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected.  Second check was made prior to prepping and draping.  Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level.  We then made an approach through a midline incision and came out over the pars.  We dissected down carefully to identify the pars.  We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level.  We did this under live fluoroscopy.  We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well.  We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars.  The pars was then drilled out.  We identified the disc even further and found the disc herniation material that was under the spinal cord.  We then took a combination of small pituitaries and removed the disc material without difficulty.  Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further.  Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well.  We could trace the nerve root out freely and easily.  We made sure there was no evidence of further disc material.  We used an Epstein curette and placed a nerve hook under the nerve root.  The Epstein curette removed some more disc material.  Once we had done this, we were satisfied with the decompression.  We irrigated the wound copiously to make sure there is no further disc material and then ready for closure.  We did place some steroid over the nerve root and readied for closure.  Hemostasis was meticulous.  The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied.  Dressing was applied.  The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  150 mL.,COMPLICATIONS: , None.,DISPOSITION:,  To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.",Thoracic Discectomy,Orthopedic,"orthopedic, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,"
"Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.","HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:",Lymphoma - Consult,Hematology - Oncology,
"Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.","PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was ""under tapped"" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.",TLIF,Orthopedic,"orthopedic, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws,"
"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.","PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",Anterior Cervical Discectomy & Fusion - 4,Neurosurgery,
"Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.","POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,",Total Abdominal Hysterectomy - Followup,Obstetrics / Gynecology,"obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative"
A 16-year-old male with Q-fever endocarditis.,"HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.",Q-Fever Endocarditis,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,"
Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass.,"PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.",Mediastinal Mass Resection,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,"
A 3-year-old abrupt onset of cough and increased work of breathing.,"ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.",Discharge Summary - Respiratory Distress,Cardiovascular / Pulmonary,
"A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.","REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved ""honors in school"" and ""looked smart.""  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently ""bang her head against the wall"" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and ""thrown two and a half city blocks.""  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and ""tunnel vision"" (vision goes smaller to a pinpoint), and she was ""spazzing out"" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test",Neuropsychological Evaluation - 2,Neurology,
The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,"DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.",Video EEG - 1,Neurology,"neurology, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic,"
Lower Extremity Arterial Doppler,"RIGHT LOWER EXTREMITY:,  The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:,  The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery.  Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,",Lower Extremity Arterial Doppler,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,"
"Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.","2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.",2-D Doppler,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,"
"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.","REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",New Onset Seizure,Neurology,
MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.,"CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with ""pins & needles"" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.",MRI T-L Spine - Schistosomiasis,Neurology,
Pain and swelling in the right foot.,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",MRI Foot - 2,Orthopedic,
"Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.","PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.",Tonsillectomy & Adenoidectomy,ENT - Otolaryngology,"ent - otolaryngology, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids"
MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",MRI Brain - Progressive Aphasia,Radiology,
Patient presents for a colostomy reversal as well as repair of an incisional hernia.,"CHIEF COMPLAINT: , ""I want my colostomy reversed."",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia.  The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a ""bag.""  According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch.  The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic.  The patient also complains of the development of an incisional hernia since his surgery in November.  He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X.  Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort.  He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Gastroesophageal reflux disease.,2.  Question of hypertension.,3.  Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4.  Status post cholecystectomy.,7.  Status post unknown foot surgery.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro.  He smokes one pack of cigarettes a day and has done so for 15 years.  He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY:  ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL:  This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light and accommodation.  Moist mucous membranes.  Extraocular movements intact.,NECK:  Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR:  Regular rate and rhythm.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with a left lower quadrant stoma.  The stoma is pink, protuberant, and productive.  The patient also has a midline incisional hernia approximately 6 cm in diameter.  It is reducible.  Otherwise, there are no further hernias or masses noted.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN:  ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis.  The patient presents for reversal of his colostomy as well as repair of his incisional hernia.  I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery.  He stated that he would try and do this and bring the records to our clinic on his next appointment.  I have also set him up for a barium enema to study the rectal stump.  He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point.  This was discussed with the patient as well as his sister and significant other in the clinic today.  They were in agreement with this plan.  We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag.  To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,",Consult for Colostomy Reversal,Gastroenterology,
MRI Brain - Right frontal white matter infarct in patient with Anticardiolipin antibody syndrome and SLE.,"CC:, Episodic monocular blindness, OS.,HX:, This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS, lasting 5-10 minutes in duration. Her vision ""greyed out"" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS, every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches.,She had no history of deep venous or arterial thrombosis.,3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were ""unremarkable."" Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly ""unremarkable."",She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable), She received Prednisone 80 mg qd for 2 days prior to presentation.,On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation.,MEDS:, Depo-Provera, Prednisone 80mg qd, and Heparin IV.,PMH:, 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation.,FHX:, Migraine headaches on maternal side, including her mother. No family history of thrombosis.,SHX:, works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.,EXAM: ,BP147/74, HR103, RR14, 37.5C.,MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes.,CN: unremarkable.,Motor: unremarkable.,Coord: unremarkable.,Sensory: decreased LT, PP, TEMP, along the lateral aspect of the left foot.,Gait: narrow-based and able to TT, HW and TW without difficulty.,Station: unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands.,COURSE: ,  ESR=108 (elevated), Hgb 11.3, Hct 33%, WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36.,She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable.,Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled), RF (negative), dsDNA, 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable.,The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events.,Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid.,She was continued on heparin IV, but despite this she continued to have occasional episodes of left monocular blindness or ""gray outs"" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home.,She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30%, WBC 5.2, MCV 89 (low), Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5.,She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96.",MRI Brain - SLE & Stroke,Neurology,
"Colonoscopy - Diarrhea, suspected irritable bowel","PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.",Colonoscopy - 4,Gastroenterology,"gastroenterology, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,"
"Phacoemulsification of cataract and posterior chamber lens implant, right eye.","OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon.  Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion.  A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe.  A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field.  A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position.  A lamellar dissection was carried anteriorly to clear cornea using a crescent knife.  A stab incision was applied with a Superblade at the 2 o'clock position at the limbus.  The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion.  Viscoat was injected into the chamber and an anterior capsulorrhexis performed.  Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber.  A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision.  A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants.  Each quadrant was emulsified under burst power within the capsular bag.  The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power.  I&A was used to aspirate cortex from the capsular bag.  A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber.  The wound was enlarged with a shortcut blade to 5.5 mm.  The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag.  The lens centralized nicely and Viscoat was removed using the I&A.  Balanced salt was injected through the side-port incision.  The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera.  The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants.  Maxitrol ointment was applied topically followed by an eye pad and shield.  The patient tolerated the procedure and was taken from the operating room in good condition.",Phacoemulsification & Lens Implantation - 4,Ophthalmology,"ophthalmology, retrobulbar nerve block, posterior chamber lens implant, phacoemulsification of cataract, lens implantation, capsular bag, cataract, phacoemulsification, nucleus, capsular, lens, eye"
A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture.,"REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.",Kyphosis,Orthopedic,"orthopedic, thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist,"
Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.,"PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:,  Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:,  Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:,  To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur.  I am bringing her back to the operating room for another exploration of this area and washout.  This will be the third procedure for this.  At the last time, there was gross purulence that was encountered.  Since that time, the patient has defervesced.  Her white count is slowly coming down.  Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:,  After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia.  The patient's right lower extremity was prepped and draped in normal sterile fashion.  Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics.  The patient's previous incision sites had the sutures removed.  We bluntly dissected down through to the IT band.  These deep stitches were then removed.  We exposed the area of the subperiosteal abscess.  The tissue looked much better than at the last surgery.  We irrigated this area with three liters of saline containing bacitracin.  Next, we made our small medial window to assist with washout of the joint itself.  We put another three liters of saline containing bacitracin through the knee joint.  Lastly, we did another three liters into the area of the distal femur with three liters of plain saline.  We then placed two Hemovac drains, one in the metaphysis and one superficially.  We closed the deep fascia with #1 PDS.  Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon.  We placed a sterile dressing.  We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN:  ,Our plan will be to pull the drains in 48 hours.  We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,",Subperiosteal Abscess Debridement,Orthopedic,"orthopedic, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess,"
"Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.","PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE:  ,Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3.  Multiple fluoroscopic views were used to ensure proper needle placement.  Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION:  ,Postprocedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to resume normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,Follow up appointment was made at the PM&R Spine Clinic in approximately 1 week.",Dorsal Ramus & Branch Block,Orthopedic,"orthopedic, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,"
"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.","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.",Telemetry Monitoring,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring,"
Electroencephalogram (EEG).  This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.,"REPORT:  ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.  The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE:  ,This is a 51-year-old male, who is being evaluated for dizziness.  Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region.  Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run.  In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION:  ,This record is essentially within normal limits.  Clinical correlation is recommended.",Electroencephalogram - 2,Neurology,"neurology, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram"
Open reduction and internal fixation of left lateral malleolus.  Left lateral malleolus fracture.,"PREOPERATIVE DIAGNOSIS: , Left lateral malleolus fracture.,POSTOPERATIVE DIAGNOSIS:,  Left lateral malleolus fracture.,PROCEDURE PERFORMED: , Open reduction and internal fixation of left lateral malleolus.,ANESTHESIA:  ,General.,TOURNIQUET TIME: , 59 minutes.,COMPLICATIONS: , None.,BLOOD LOSS: , Negligible.,CLOSURE: , 2-0 Vicryl and staples.,INDICATIONS FOR SURGERY:,  This is a young gentleman with soccer injury to his left ankle and an x-ray showed displaced lateral malleolus fracture with widening of the mortise now for ORIF.  The risks and perceivable complications of the surgeries were discussed with the patient via a translator as well as nonsurgical treatment options and this was scheduled emergently.,OPERATIVE PROCEDURE: , The patient was taken to the operative room where general anesthesia was successfully introduced.  The right ankle was prepped and draped in standard fashion.  The tourniquet was applied about the right upper thigh.  An Esmarch tourniquet was used to exsanguinate the ankle.  The tourniquet was insufflated to a pressure 325 mm for approximately 59 minutes.  An approximately 6 inch longitudinal incision was made just over the lateral malleolus.  Care was taken to spare overlying nerves and vessels.  An elevator was used to expose the fracture.  The fracture was freed of old hematoma and reduced with a reducing clamp.  An interfragmentary cortical screw was placed of 28 mm with excellent purchase.  The intraoperative image showed excellent reduction.  A 5-hole semitubular plate was then contoured to the lateral malleolus and fixed with 3 cortical screws proximally and 2 cancellous screws distally.  Excellent stability of fracture was achieved.  Final fluoroscopy showed a reduction to be anatomic in 2 planes.  The wound was irrigated with copious amounts of normal saline.  Deep tissue was closed with 2-0 Vicryl.  The skin was approximated with 2-0 Vicryl and closed with staples.  Dry sterile dressing was applied.,The patient tolerated the procedure, was awakened and taken to the recovery room in stable condition.",ORIF - Malleolus,Orthopedic,"orthopedic, open reduction and internal fixation, esmarch, internal fixation, malleolus fracture, lateral malleolus, tourniquet, orif, fixation, ankle, reduction, fracture, malleolus"
Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,"ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, ""mass like"" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.",Pneumonia & COPD - Discharge Summary,Cardiovascular / Pulmonary,
"Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.","PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",Umbilical Hernia Repair - 1,Gastroenterology,"gastroenterology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,"
"Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.","PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.",Anterior Cervical Decompression,Orthopedic,"orthopedic, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,"
"Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.","PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE:  ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.,ANESTHESIA: , General endotracheal.,SPECIMEN:,  Left chest wall with tumor and left lower lobe lung wedge resection to pathology.,INDICATIONS FOR PROCEDURE:,  The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased.  Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening.  A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma.  The patient had a metastatic workup, which was negative including a brain MRI and bone scan.  The bone scan showed only signal positivity in the left 9th rib near the tumor.  The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia.  He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  The patient was intubated with a double-lumen endotracheal tube.  Intravenous antibiotics were given.  A Foley catheter was placed.  The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion.  An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass.  The skin and subcutaneous tissues were dissected sharply with the electrocautery.  Good hemostasis was obtained.  The tumor was easily palpable and clearly involving the 8th to 9th rib.  A thoracotomy was initially made above the mass in approximately the 7th intercostal space.  Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection.  The thoracotomy was extended anteriorly and posteriorly.  It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected.  The ribs of the chest wall were first cut at their anterior aspect.  The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery.  Hemostasis was obtained with both electrocautery and clips.  The chest wall segment to be resected was retracted laterally and posteriorly.  It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement.  Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor.  The spleen and the stomach were identified and were protected.  Inferiorly, the resection of the chest wall was continued in the 10th interspace.  The dissection was then carried posteriorly to the level of the spine.  The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung.  A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection.  Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies.  The ribs were disarticulated, closed to or at their articulations with the spine.  Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery.  There was no disease grossly involving or encasing the aorta.,The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section.  The specimen was oriented for the pathologist who came to the room.  Hemostasis was obtained.  The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures.  This produced a satisfactory diaphragmatic repair without undue tension.  A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly.  This was secured with a #1 silk suture.  The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect.  A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually.  The resulting mesh closure was snug and deemed adequate.  The serratus muscle was reapproximated with figure-of-8 0 Vicryl.  The latissimus was reapproximated with a two #1 Vicryl placed in running fashion.  Of note, two #10 JP drains were placed over the mesh repair of the chest wall.  The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl.  The wounds were dressed.  The patient was brought from the operating room directly to the North ICU, intubated in stable condition.  All counts were correct.,",Chest Wall Tumor Resection,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest wall tumor resection, diaphragm, left lower lobe, lung wedge resection, chest wall reconstruction, chest wall segment, gore tex mesh, chest wall tumor, chest wall, pleural cavity, lower lobe, wedge resection, resection, tumor, wall, chest, anesthesia, electrocautery, wedge, mesh, lung,"
The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,"HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.",CyberKnife Treatment - Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,"
Patient with worsening shortness of breath and cough.,"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.",Trouble breathing,Cardiovascular / Pulmonary,
"Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy","PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.",Stamm Gastrostomy Tube Placement,Gastroenterology,
Direct current cardioversion.  Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.,"PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits including risk of stroke.  The patient understands as well as her husband.  The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium.  There was spontaneous echocardiogram contrast noticed.  The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed.  The pads applied in the anterior and posterior approach.  With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm.  The patient had some occasional PACs noticed with occasional sinus tachycardia.  The patient had no immediate post-procedure complications.  The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION:  ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.",Cardioversion - Direct Current,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion"
"Specimen labeled ""sesamoid bone left foot"".","GROSS DESCRIPTION: , Specimen labeled ""sesamoid bone left foot"" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm.  The specimen is entirely submitted, after decalcification.,DIAGNOSIS:,  Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue.  Arteriosclerosis, severely occlusive.",Pathology - Sesamoid Bone,Orthopedic,"orthopedic, marrow fibrosis, osteomyelitis, arteriosclerosis, inflammation of fascia, specimen, fragmentsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension.  Cervical intraepithelial neoplasia grade-III postconization.  Recurrent dysplasia.  Uterine procidentia grade II-III.  Mild vaginal vault prolapse.,"PREOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2.  Recurrent dysplasia.,3.  Unable to follow in office.,4.  Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III postconization.,2.  Poor margins.,3.  Recurrent dysplasia.,4.  Uterine procidentia grade II-III.,5.  Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1.  Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2.  Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS:  ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS:  ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS:  ,On bimanual examination, the uterus was found to be small.  There were no adnexal masses appreciated.  Intraabdominal findings revealed a small uterus approximately 2 cm in size.  The ovaries were atrophic consistent with menopause.  The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control.  She was then placed in the dorsal lithotomy position and administered general anesthesia.  She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder.  At this point, the patient was evaluated for a possible vaginal hysterectomy.  She was nulliparous and the pelvis was narrow.  After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy.  After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis.  The second scalpel was used to dissect out to the underlying layer of fascia.  The fascia was incised in the midline and extended laterally using the Mayo scissors.  The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors.  In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors.  The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum.  The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.  At this point, the above findings were noted and the GYN Balfour retractor was placed.  Moist laparotomy sponges were used to pack the bowel out of the operative field.  The bladder blade and the extension for the retractor were then placed.  An Allis was used on the uterus for retraction.  The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated.  The anterior portion of the broad ligament was dissected along vesicouterine resection.  The bladder was then dissected off the anterior cervix and vagina without difficulty.  The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture.  The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl.  Good hemostasis was assured.  The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl.  Good hemostasis was obtained.  Two hemostats were then placed just under the cervix meeting in the midline.  The uterus and cervix were then _______ off using a scalpel.  This was handed and sent to Pathology for evaluation.  Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament.  A baseball stitch was then used to close the cuff to the midline.  The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments.  The baseball stitch was used to close the cuff to the midline.  The hemostats were removed and the cuff was closed and good hemostasis was noted.  The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff.  The pelvis was then copiously irrigated with warm normal saline.  Good support and hemostasis was noted.  The bowel packing was then removed and the GYN Balfour retractor was moved.  The peritoneum was then repaired with #0 Vicryl in a running fashion.  The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this.  The patient was then brought out of general anesthesia and extubated.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will follow up postoperatively as an inpatient.",TAH & Salpingooophorectomy,Obstetrics / Gynecology,"obstetrics / gynecology, cervical intraepithelial neoplasia, vaginal vault prolapse, uterosacral ligament vault suspension, total abdominal hysterectomy, bilateral salpingooophorectomy, abdominal hysterectomy, uterosacral ligament, recurrent dysplasia, uterine procidentia, suture ligated, abdominal, intraepithelial, tah, salpingooophorectomy, hysterectomy, ligament, hemostats, vaginal,"
Placement of a subclavian single-lumen tunneled Hickman central venous catheter.  Surgeon-interpreted fluoroscopy.,"PROCEDURE PERFORMED,1.  Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered.  Next, a #18-gauge needle was used to locate the subclavian vein.  After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique.  The needle was withdrawn.  The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff.  The catheter was cut to the appropriate length.  A dilator and sheath were passed over the J wire.  The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  The catheter was flushed and aspirated without difficulty.  The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  A 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  The skin stab site was closed with a 4-0 Monocryl.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.",Hickman Central Venous Catheter Placement,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Right carpal tunnel release and right index and middle fingers release A1 pulley.  Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.,"PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.",Carpal Tunnel Release - 8,Orthopedic,"orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,"
"Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.","ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.",Multiple Medical Problems - Discharge Summary,Gastroenterology,
"Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.","HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.",EMG/Nerve Conduction Study - 7,Neurology,"neurology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,"
Resting Myoview and adenosine Myoview SPECT,"PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.",Mayoview,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,"
"Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.","SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.",Orthopedic Consult - 1,Orthopedic,"orthopedic, low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, pes, spinal, spondylosis, sacroiliac, syndrome,"
A sample note on pre-eclampsia & eclampsia.,"PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised.  It usually occurs from the 20th week of pregnancy to 7 days postpartum.  The cause is unknown.  It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process.  The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years.  There are identifiable risk factors for developing pre-eclampsia:  family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy).  A chronic high blood pressure and underlying blood vessel disease increases the risk.  Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage.  Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,*  Significant blood pressure increase even if you are still within the normal blood pressure limits.,*  Swelling in the face, hands and feet which worsens in the a.m.,*  Gaining more than a pound a week, especially in the last trimester.,*  Routine prenatal checkup reveals protein in the urine.,*  Seizures are possible.,SEVERE PRE-ECLAMPSIA:,*  More blood pressure increase.,*  Further swelling in face, hands and feet.,*  Visual disturbances.,*  Headache.,*  Irritability.,*  Abdominal pain.,*  Tiredness.,*  Decreased urination.,*  Seizures possible.,*  Nausea and vomiting.,ECLAMPSIA:,*  Symptoms worsen.,*  Seizures.,*  Muscle twitches.,*  Coma.,TREATMENT:,*  Diagnosis - blood tests, urinalysis, blood pressure monitoring.,*  Mild preeclampsia can be treated at home.  Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,*  Daily weighing.,*  Daily monitoring for protein in urine.,*  Medications to lower blood pressure if preeclampsia is severe.,*  Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,*  Get lots of rest! Lay on your left side to help circulation.,*  Follow any dietary advice given by your doctor.,*  Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,*  Never take any medications that are not prescribed or recommended by your physician.,*  Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda.  In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration.  For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.",Pre-Eclampsia & Eclampsia,Obstetrics / Gynecology,
Pulmonary Function Test to evaluate dyspnea.,"HISTORY:,  Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:,  FVC was 59%.  FEV1 was 61%.  FEV1/FVC ratio was 72%. The predicted was 70%.  The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  SVC was 69%. Inspiratory capacity was 71%.  Expiratory residual volume was 61%.  The TGV was 94%.  Residual volume was 113% of its predicted.  Total lung capacity was 83%.  Diffusion capacity was diminished.,IMPRESSION:,1.  Moderate restrictive lung disease.,2.  Some reversible small airway obstruction with improvement with bronchodilator.,3.  Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4.  Flow volume loop was consistent with the above and no upper airway obstruction.,",Pulmonary Function Test - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lung, capacity"
The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.,"She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was ""immune"" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.",Shortness Of Breath - Progress Note,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE"
Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.,"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,",Anterior Cervical Discectomy & Interbody Fusion - 3,Neurosurgery,"neurosurgery, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,"
Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.",Arthroscopic Rotator Cuff Repair,Orthopedic,
"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.","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.",Telemetry Monitoring,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring,"
Phacoemulsification with intraocular lens placement.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.,"PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE:  ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops.  Topical anesthetic drops were applied to the eye just prior to entering the operating room.  The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.  Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber.  A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.",Phacoemulsification & Lens Implantation - 2,Ophthalmology,"ophthalmology, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye,"
"Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.","FAMILY HISTORY:,  Her father died from leukemia.  Her mother died from kidney and heart failure.  She has two brothers; five sisters, one with breast cancer; two sons; and a daughter.  She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:,  She is divorced.  She does not have support at home.  She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed.  She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:,  Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:,  In 1979, tubal ligation and three milk ducts removed.  In 1989 she had a breast biopsy and in 2007 a colonoscopy.  She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS:  ,HEENT:  For headaches and sore throat.  Musculoskeletal:  She is right handed with joint pain, stiffness, and decreased range of motion.  Cardiac:  For heart murmur.  GI:  Negative and noncontributory.  Respiratory:  Negative and noncontributory.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.  Genital:  Negative and noncontributory.  She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall.  Current weight is 132 pounds, weight one year ago was 126 pounds.  BP is 122/68.  On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  General, a well-developed and well-nourished female in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth good dentition.  Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movement.  Cranial nerve VIII, hearing intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  Examination of the low back reveals some mild paralumbar spasms.  She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature.  She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation.  Deep tendon reflexes are 2+ bilateral knees and ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Straight leg raising is negative bilaterally.  Strength on manual exam is 5/5 and equal bilateral lower extremity.  She is able to ambulate on her toes and her heels without any difficulty.  She is able to get up standing on one foot on to the toes.  She does have some difficulty getting up on to her heels when standing on one foot.  She has trouble with this on the left and right.  She complains of increased pain while doing this as well.  She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left.  Sensation is intact.  She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout.  At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged.  At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear.  This could represent a facet synovial cyst.  This is lateral to the facet.  She does not have x-rays for review.  She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1  Do nothing.,2.  Conservative therapies.,3.  Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays.  We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that.  After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing.  All questions and concerns were addressed.  If she should have any further questions, concerns, or complications, she will contact our office immediately.  Otherwise, we will see her as scheduled.  Case was reviewed and discussed with Dr. L.",Lumbar Radiculopathy - Consult,Orthopedic,"orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia,"
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.,"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.",Transesophageal Echocardiogram - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,"
Repeat cesarean section and bilateral tubal ligation.,"PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,PROCEDURE PERFORMED:  ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  800 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term.  The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization.  The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie.  The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted.  The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  The placenta was delivered spontaneously intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology.  Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected.  Hemostasis was visualized bilaterally.  The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic.  The uterine incision was reexamined and it was noted to be hemostatic.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.",Repeat C-section,Obstetrics / Gynecology,"obstetrics / gynecology, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean,"
Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,"REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.",Pacemaker (Single Chamber) - 2,Cardiovascular / Pulmonary,
"Re-excision of squamous cell carcinoma site, right hand.","PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.",Excision of Squamous Cell Carcinoma,Hematology - Oncology,"hematology - oncology, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma"
"Total vaginal hysterectomy.   Menometrorrhagia, dysmenorrhea, and small uterine fibroids.","ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.",Hysterectomy - Discharge Summary - 1,Obstetrics / Gynecology,"obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,"
Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used.   A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.,"PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,PROCEDURE PERFORMED:  ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops.  Topical 4% lidocaine drops were used.  The patient was prepped and draped in the normal sterile fashion.  A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.  This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  This was exchanged for Viscoat solution.  Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps.  Balanced salt solution was used to hydrodissect the nucleus.  Nuclear material was removed via phacoemulsification with divide-and-conquer technique.  The residual cortex was removed via irrigation and aspiration.  The capsular bag was then filled with Provisc solution.  The wound was slightly enlarged.  The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye.  The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact.  The lens was well centered in the capsular bag.  The anterior chamber was deep.  The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly.  Maxitrol ointment was placed into the eye.  The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.",Phacoemulsification & Cataract Extraction - 5,Ophthalmology,"ophthalmology, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,"
"Cataract, right eye.  Phacoemulsification with intraocular lens placement, right eye.","PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.",Phacoemulsification & Lens Implantation - 3,Ophthalmology,"ophthalmology, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular"
Follow up update on patient with left carotid angioplasty and stent placement.,"Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,",Cardiology - Letter,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
"Right open carpal tunnel release and cortisone injection, left carpal tunnel.","PREOPERATIVE DIAGNOSIS:  ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1.  Right open carpal tunnel release.,2.  Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,INDICATIONS:,  This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  He is scheduled for the above-mentioned procedures.  The planned procedures were discussed with the patient including the associated risks.  The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  Informed consent was obtained.  The patient was then brought to the operating room and transferred to the operating table in supine position.  Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Planned skin incision was marked along the base of the patient's right palm.  Right upper extremity was then exsanguinated using Esmarch.  The tourniquet was then inflated to 250 mmHg.  Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  Bleeding points were identified with electrocautery using bipolar electrocautery.  Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  This was confirmed by visually and palpably.  Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  Carpal canal was then inspected.  The median nerve was flattened and injected.  No other abnormalities were noted.  Wounds were then irrigated with normal saline and antibiotic additive.  Decadron 4 mg was then placed adjacent to the median nerve.  Skin incision was then closed with interrupted 5-0 nylon suture.  The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban.  The tourniquet was then deflated.  Attention was then directed to the left side.  Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine.  Band-Aid was then placed over the injection site.  The patient was then awakened, extubated, and transferred over to his hospital bed.  He was transported to recovery room in stable condition.  There were no intraoperative or immediate postoperative complications.  All counts were reported as correct.",Carpal Tunnel Release - 4,Orthopedic,"orthopedic, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,"
Pain and swelling in the right foot.,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",MRI Foot - 3,Orthopedic,
"Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.","PROCEDURES,1.  Arthroscopic rotator cuff repair.,2.  Arthroscopic subacromial decompression.,3.  Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given general anesthetic.  Once the patient was under general anesthetic, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  The patient was then carefully positioned into a beach-chair position.  We maintained the natural alignment of the head, neck, and thorax at all times.  The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery.  We injected the glenohumeral joint with sterile saline with a spinal needle.  This consisted of 60 cc of fluid.  We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition.  There was a superior labral tear (SLAP).  This was extensively debrided using a shaver through an anterior portal.  We also found a full thickness rotator cuff tear.  We then drained the glenohumeral joint.  We redirected our camera into the subacromial space.  An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver.  The bursa was extensively debrided.  We then abraded the bone over the footprint of where the rotator cuff is usually attached.  The corkscrew anchors were used to perform a rotator cuff repair.  Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed.  It was carefully positioned.  Pictures were taken.  We then drained the joint.  All instruments were removed.  The patient did receive IV antibiotic preoperatively.  All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump.  ABD, tape, and a sling were also applied.  A Cryo/Cuff was also placed over the shoulder.  The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  The patient was extubated and brought to the recovery room in stable condition.  I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.",Arthroscopic Rotator Cuff Repair - 2,Orthopedic,"orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff,"
Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,"ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.",ORIF - Discharge Summary,Orthopedic,"orthopedic, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,"
Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix.,"ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.",Hysterectomy - Discharge Summary - 2,Obstetrics / Gynecology,"obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,"
Left lower extremity venous Doppler ultrasound,"LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.",Lower Extremity Venous Doppler,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,"
Patient returns to Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.,"SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema.  She was last seen in the clinic in March 2004.  Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable.  She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  She does have occasional cough and a small amount of sputum production.  No fever or chills.  No chest pains.,CURRENT MEDICATIONS:,  The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:,  Erythromycin.,REVIEW OF SYSTEMS:,  Significant for problems with agitated depression.  Her respiratory status is unchanged as noted above.,EXAMINATION:,General:  The patient is in no acute distress.,Vital signs:  Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular:  Distant heart tones.  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1.  Chronic obstructive pulmonary disease/emphysema, severe but stable.,2.  Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3.  History of depression and schizophrenia.,PLAN:,  At this point, I have recommended that she continue current respiratory medicine.  I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading.  I have recommended that she use it with activity and at night.  I spoke with her about her living situation.  Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment.  Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.",Pulmonary Medicine Clinic Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary,"
"Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.","PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.",Lumbar Laminectomy,Orthopedic,"orthopedic, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,"
"Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.","PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.",Vein Stripping,Neurology,"neurology, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,"
Laparoscopic appendectomy.  Acute appendicitis.,"PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.",Laparoscopic Appendectomy,Gastroenterology,"gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,"
"Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.  Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.","PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.",Osteosynthesis,Orthopedic,"orthopedic, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral"
"Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter.  The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.","HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here.  Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1.  Atenolol 25 mg once a day.,2.  Altace 2.5 mg once a day.,3.  Zocor 20 mg once a day.,4.  Flecainide 200 in the morning and 100 in the evening.,5.  Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE.  HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well.  The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  No use of illicit drugs.  He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife.  He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18.  On general exam, he is a pleasant overweight gentleman, in no acute distress.  HEENT:  Shows cranium is normocephalic and atraumatic.  He has moist mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin warm and perfused.  Affect appropriate.  He is quite oriented and pleasant.  No significant kyphoscoliosis on recumbent back exam.  Lungs are clear to auscultation anteriorly.  No wheezes.  No egophony.  Cardiac Exam:  S1, S2.  Regular rate, controlled.  No significant murmurs, rubs or gallops.  PMI is nondisplaced.  Abdomen is soft, nondistended, appears benign.  Extremities without significant edema.  Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:,  Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null.  The patient expressed understanding of this risk, benefit, and alternative analysis.  I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE:  ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  The patient did actively participate in this time-out procedure.  After the universal protocol was done, he then received the cardioversion attempt with 50 joules using ""lollipop posterior patch"" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22.  We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed.  I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself.  Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.",Cardiac Consult & Cardioversion,Cardiovascular / Pulmonary,
Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.,"PREOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:,  ,1.  Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2.  Neck pain with left radiculopathy, progressive (723.1/723.4).,3.  Headaches, progressive (784.0).,PROCEDURES:,  ,1.  Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2.  Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3.  Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE:  ,  Neurosurgery,ANESTHESIA:,",Anterior Cervical Discectomy & Interbody Fusion - 3,Orthopedic,"orthopedic, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,"
Diagnostic cerebral angiogram and transcatheter infusion of papaverine,"EXAM:,1.  Diagnostic cerebral angiogram.,2.  Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:,  Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm.  He was referred for a routine postop check angiogram.  He is doing fine clinically.  All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  Patient was placed under general anesthesia for entire duration of the procedure.  Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1.  After that the diagnostic catheter was taken up into the distal internal carotid artery.  SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire.  The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1.  The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1.  LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS:  The left internal carotid artery is of normal caliber.  In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1.  There is poor filling of the A2 through left internal carotid artery injection.  There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally.  Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2.  RIGHT INTERNAL CAROTID ARTERY INJECTION:  The right internal carotid artery is of normal caliber.  There is opacification of the right ophthalmic and the posterior communicating artery.  The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery.  Right MCA along with the distal branches are filling normally.  Capillary filling and venous drainage are normal.,3.  POST-PAPAVERINE INJECTION:  The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1.  Well clipped left ICA bifurcation aneurysm.,2.  Moderately severe spasm of the internal carotid artery and left A1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.",Diagnostic Cerebral Angiogram,Neurology,"neurology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine,"
"CT Brain: Suprasellar aneurysm, pre and post bleed.","CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.",CT Brain - Aneurysm,Neurology,"neurology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,"
CCTA with Cardiac Function/Calcium Scoring,"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.",Coronary CT Angiography (CCTA) - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,"
"Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.","PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.",Anterior Lumbar Fusion,Orthopedic,"orthopedic, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,"
The patient had undergone mitral valve repair about seven days ago.,"PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.",Mediastinal Exploration & Right Atrium Repair,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,"
Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study.,"CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½"".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5"".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.",Pulmonary Consultation - 2,Cardiovascular / Pulmonary,
Cerebral Angiogram - moyamoya disease.,"CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.",Moyamoya Disease,Neurology,
Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube.,"PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.",Myringotomy/Tube Insertion - 3,ENT - Otolaryngology,
"Right shockwave lithotripsy, cystoscopy, and stent removal x2.","PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.",Shockwave Lithotripsy,Nephrology,"nephrology, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone"
"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.","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.",Thoracotomy & Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,"
"Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.","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.",Admission History & Physical - Nausea,Gastroenterology,"gastroenterology, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery,"
MRI L-Spine - Bilateral lower extremity numbness,"CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.",Normal L-Spine MRI,Orthopedic,"orthopedic, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness"
Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.,"REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.",Sepsis - Consult,Hematology - Oncology,
Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal.,"REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.",Electroencephalogram - 1,Neurology,"neurology, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Left Iliopsoas hematoma.  Gait difficulty.,"CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of ""swollen left foot."" These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.",Iliopsoas Hematoma - 1,Neurology,
Transesophageal echocardiogram and direct current cardioversion.,"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.",Transesophageal Echocardiogram,Radiology,
Esophagogastroduodenoscopy performed in the emergency department.,"PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.",Esophagogastroduodenoscopy - 13,Gastroenterology,"gastroenterology, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,"
Pain and swelling in the right foot.,"EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",MRI Foot - 2,Radiology,
Implantation of a dual chamber permanent pacemaker,"CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.",Pacemaker (Dual Chamber),Cardiovascular / Pulmonary,"cardiovascular / pulmonary, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,"
A 21-channel digital electroencephalogram was performed on a patient in the awake state.,"PROCEDURE:,  A 21-channel digital electroencephalogram was performed on a patient in the awake state.  Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity.  Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  The episodes last from approximately1 to 7 seconds.  The episodes are exacerbated by hyperventilation.,IMPRESSION:,  Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  This activity could represent true petit mal epilepsy.  Clinical correlation is suggested.",Electroencephalogram - 4,Neurology,"neurology, alpha activity, wave activity, hyperventilation, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Bilateral open carpal tunnel release.,"PREOPERATIVE DIAGNOSIS:  ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:,  General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE:  ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities.  The right upper extremity was exsanguinated, and the tourniquet inflated.  A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament.  This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon.  The wound was injected, and a dry, sterile dressing was applied.  An identical procedure was done to the opposite side.  The patient left the operating room in satisfactory condition.",Carpal Tunnel Release - 5,Orthopedic,"orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal"
Pilonidal cyst with abscess formation.  Excision of infected pilonidal cyst.,"PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:,  Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room.  A time-out process was followed.  Antibiotics were given and then the patient was prepped and draped in the usual fashion.  It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating.  An elliptical excision of all infected tissues down to the coccyx was performed.  Hemostasis was achieved with a cautery.  The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition.  Estimated blood loss was minimal.  The patient tolerated the procedure well.",Pilonidal Cyst Excision,Hematology - Oncology,"hematology - oncology, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,"
"Excision of foreign body, right foot and surrounding tissue.  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.","PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:,  Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:,  This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot.  The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe.  The wire entered his foot.  His family physician attempted to remove the wire, but it only became deeper in the foot.  The wound eventually healed, but a scar tissue was formed.  The patient has had constant pain with ambulation intermittently since the incident occurred.  He desires attempted surgical removal of the wire.  The risks and benefits of the procedure have been explained to the patient in detail by Dr. X.  The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered into the operative field and the sterile stockinet was reflected.  Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized.  This was the origin and entry point of the previous puncture wound from the wire.  This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area.  Next, the Xi-scan was draped and brought into the operating room.  A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire.  Next, a #10 blade was used to make approximately a 3 cm curvilinear ""S""-shaped incision.  Next, the #15 blade was used to carry the incision through the subcutaneous tissue.  The medial and lateral margins of the incision were undermined.  Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning.  Therefore, they were removed.  Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped.  A second hemostat was used to clamp the wire.  A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound.  The wire quickly came into visualization.  It measured approximately 4 mm in length and was approximately 1 mm in diameter.  The wire was green colored and metallic in nature.  It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification.  The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament.  Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected.  Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space.  Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique.  The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied.  The pneumatic ankle tourniquet was released.  There was immediate hyperemic flush to the digits noted.  The patient's anesthesia was reversed.  He tolerated the above anesthesia and procedure without complications.  The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot.  He was given OrthoWedge shoe.  Ice was applied behind the knee and his right lower extremity was elevated on to pillows.  He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity.  He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed.  He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise.  He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose.  He was given crutches.  He was discharged in stable condition.",Foreign Body Removal - Foot,Orthopedic,"orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,"
"Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.","REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.",Hematology Consult,Hematology - Oncology,
MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",MRI Brain - Toxoplasmosis,Radiology,
"Colonoscopy with photos.  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.","PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.",Colonoscopy With Photos,Gastroenterology,"gastroenterology, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope"
"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","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.",Sick Sinus Syndrome,Cardiovascular / Pulmonary,
"Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.","Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.",Cardiovascular - Letter,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin"
CT of the abdomen and pelvis without contrast.,"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.",CT Abdomen & Pelvis - 3,Gastroenterology,"gastroenterology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,"
Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.,"CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.",ER Report - Stomach Pain,Gastroenterology,
MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH),"CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He ""knew what he wanted to say, but could not say it."",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as ""up"" or ""down"". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.",MRI Brain - Progressive Aphasia,Neurology,
Sports physical with normal growth and development.,"HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.",Sports Physical - 2,Pediatrics - Neonatal,
"Irritable baby, 6-week-old, with fever for approximately 24 hours.","CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.",H&P - Infant with fever,Pediatrics - Neonatal,
"Selective coronary angiography, left heart catheterization, and left ventriculography.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","NAME OF PROCEDURES,1.  Selective coronary angiography.,2.  Left heart catheterization.,3.  Left ventriculography.,PROCEDURE IN DETAIL:  ,The right groin was sterilely prepped and draped in the usual fashion.  The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed.  Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg.  A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery.  Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed.  This was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed.  A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  The left heart pullback was performed.  The catheter was removed and a small injection of contrast was given to the sheath.  The sheath was removed over a wire and an Angio-Seal was placed.  There were no complications.  Total contrast media was 200 mL of Optiray 350.  Fluoroscopy time 5.3 minutes.  Total x-ray dose is 1783 mGy.,HEMODYNAMICS:  ,Rhythm is sinus throughout the procedure.  LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg.  LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease.  This also gives rise to the conus branch and two RV free wall branches.  The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  This vessel then bifurcates into the LAD and circumflex.  The circumflex is a large caliber vessel and is dominant.  This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA.  There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic.  The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  The overall ejection fraction is preserved.  There is moderate dilatation of the aortic root.  The calculated ejection fraction is 63%.,IMPRESSION,1.  Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  There is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  A 60% stenosis in the distal circumflex.,4.  Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.","Heart Catheterization, Ventriculography, & Angiography - 12",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography"
"DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,","PROCEDURES PERFORMED:,1.  DDDR permanent pacemaker.,2.  Insertion of a steroid-eluting screw in right atrial lead.,3.  Insertion of a steroid-eluting screw in right ventricular apical lead.,4.  Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length.  They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure.  The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner.  We also scrubbed for approximately eight minutes.  Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized.  Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein.  The Cook needles were removed.  Then the guidewires were secured in place with hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle.  The skin was then undermined making a pocket for the generator.  The guidewires were then tunneled through the performed pocket.  Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively.  Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed.  After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead.  After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture.  The leads were then connected to a pulse generator.  The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket.  The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dry.  Steri-Strips and pressure dressing were applied.  The patient tolerated the procedure well.  There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name:  Sigma.,Model #:  SDR203.,Serial #:  123456.,ATRIAL LEAD,Model #:  4568-45 cm.,Serial #:  123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #:  4068-52 cm.,Serial #:  123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking.  Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking.  The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well.  There were no complications.  The patient went to Recovery in satisfactory condition.  Family was updated.  Orders are all in the chart.  Please see orders.,Again, thank you for allowing to participate in this care.",DDDR Permanent Pacemaker,Cardiovascular / Pulmonary,
The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,"REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated ""diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined.""  It concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test",Neuropsychological Evaluation - 4,Psychiatry / Psychology,
"An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.","HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped.  Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker.  An ECG this morning showing normal sinus rhythm with frequent APCs.  Her potassium at that time was 3.1.  She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  She denies any chest pain nor shortness of breath prior to or since the fall.  She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure.  On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative.  She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker.  She does have a history of significant hypertension in the past.  She has had dizzy spells and denies clearly any true syncope.  She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1.  Multivitamin p.o. daily.,2.  Aspirin 325 mg once a day.,3.  Lisinopril 40 mg once a day.,4.  Felodipine 10 mg once a day.,5.  Klor-Con 20 mEq p.o. b.i.d.,6.  Omeprazole 20 mg p.o. daily presumably for GERD.,7.  MiraLax 17 g p.o. daily.,8.  Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN.  IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:,  She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  She is retired from Morse Chain and delivering newspapers.  She is widowed.  She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  She does note occasional peripheral edema.  She is not aware of prior history of MI.  She denies diabetes.  She does have a history of GERD.  She notes feeling depressed at times because of living alone.  She denies rheumatologic conditions including psoriasis or lupus.  Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM:  ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%.  On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  HEENT:  Shows cranium is  normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins were not distended.  There are no carotid bruits.  Lungs:  Clear to auscultation anteriorly without wheezes.  She is relatively immobile because of her left hip fracture.  Cardiac Exam:  S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  There is also a soft holosystolic murmur heard.  There is no rub or gallop.  PMI is nondisplaced.  Abdomen is soft and nondistended.  Bowel sounds present.  Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  Pulses appear grossly intact.  Affect is appropriate.  Visible skin warm and perfused.  She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  No clear pulmonary vascular congestion.  Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  Troponin was 0.03 followed by 0.18.  INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed.  Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes.  She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior.  Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION:  ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected.  There has been no atrial fibrillation documented.  I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  She actually describes feeling good exercise capacity prior to this fall.  Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  Continued optimization of electrolytes.  The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge.  Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.",Hypertension - Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,"
Newly diagnosed cholangiocarcinoma.  The patient is noted to have an increase in her liver function tests on routine blood work.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.,"REASON FOR CONSULTATION:,  Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009.  Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.  Common bile duct was noted to be 10 mm in size on that ultrasound.  She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm.  She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct.  She was then referred to gastroenterology and underwent an ERCP.  On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography.  She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma.  A temporary biliary stent was placed across the biliary stricture.  Blood work was obtained during the hospitalization.  She was also noted to have an elevated CA99.  She comes in to clinic today for initial Medical Oncology consultation.  After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY:  ,Significant for hypertension and hyperlipidemia.  In July, she had eye surgery on her left eye for a muscle repair.  Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease.  She had three brothers that died of complications from open heart surgery.  Her parents and brothers all had hypertension.  Her younger brother died at the age of 18 of infection from a butcher's shop.  He was cutting Argentinean beef and contracted an infection and died within 24 hours.  She has one brother that is living who has angina and a sister who is 84 with dementia.  She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years.  Her first husband died in 1995.  She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS:  ,The patient reports a change in her bowels ever since she had the stent placed.  She has noted some weight loss, but she notes that that is due to not eating very well.  She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms.  As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup.  She has had some difficulty with her vision that has improved with her recent surgical procedure.  She denies any fevers, chills, night sweats.  She has had loose stools.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:",Cholangiocarcinoma Consult,Hematology - Oncology,
"Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.","TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.",Laminectomy & Discectomy & Facetectomy,Orthopedic,"orthopedic, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,"
A 37 year-old female with twin pregnancy with threatened premature labor.,"GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:",Ultrasound OB - 3,Radiology,
CT cervical spine for trauma.  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine.",CT C-Spine - 2,Orthopedic,"orthopedic, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE"
MRI Brain & T-spine - Demyelinating disease.,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.",MRI Brain & T-spine - Demyelinating disease.,Neurology,"neurology, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain,"
Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,"PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.",Carpal Tunnel Release - 9,Orthopedic,"orthopedic, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median,"
Patient with back and hip pain.,"Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,In May 2002, as part of a vascular work-up for the patient’s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,Past Medical History:,End stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,Hypertension,Peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002,Peripheral Neuropathy,Chronic anemia (on Epogen injections),History of several partial small bowel obstructions - six times during the last 10 years,Past Surgical History:,1. Tonsillectomy and adenoidectomy (1943),2. Left ureter re-implantation (1960),3. Repair of splenic artery aneurysm (1968),4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988),5. Cadaveric renal transplant (1988),6. Cataract surgery in bilateral eyes,Medications:,1. Imuran 100mg po QD,2. Prednisone 7.5mg po QD,3. Aspirin 81mg po QD,4. Trental 400mg po TID,5. Norvasc 5mg po BID,6. Prinivil 20mg po BID,7. Hydralazine 50mg po Q6H,8. Clonidine TTS III on Thursdays,9. Terasozin 5mg po BID,10. Elavil 30mg po QHS,11. Vicodin 1-2tabs po Q6H prn,12. Epoetin SR 10,000Units SQ QM and F,13. Sodium bicarbonate 648mg po QD,14. Calcium carbonate 2gm po QID,15. Docusate sodium 100mg po QD,16. Chocolate Ensure one can po QID,17. Multivitamin,18. Vitamin E,Social History:, The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.,Allergies:, No known drug allergies.,Family History:",Orthopedic Consult - 1,Orthopedic,
Squamous cell carcinoma of right temporal bone/middle ear space.  Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,"PREOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the operating room, placed on the table in supine position.  General endotracheal anesthesia was obtained in the usual fashion.  The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen.  The neck was prepped as well.  After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl.  A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle.  After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible.  The condyle was skeletonized so that it could be easily seen.  The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared.  The neck contents to the hyoid were dissected out.  The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen.  The neck contents were removed as a separate specimen.  The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis.  A large posterior facial vein was identified and likewise clipped for later use.  I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb.  It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube.  The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made.  I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion.  Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy.  For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap.  A skin paddle was drawn out next to the umbilicus about 4 x 4 cm.  The skin paddle was incised with the Bovie and down to the anterior rectus sheath.  Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle.  The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin.  The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl.  The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction.  The vascular pedicle could be seen entering the muscle in usual fashion.  The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel.  The wound was then packed with saline impregnated sponges.  The rectus muscle with attached skin paddle was then transferred into the neck.  The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique.  Ischemia time was less than 10 minutes.  Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well.  There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case.  The wound was irrigated with copious amounts of saline.  The eustachian tube was obstructed with bone wax.  The muscle was then laid into position with the skin paddle underneath the conchal bowl.  I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place.  The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull.  The subcutaneous tissues were closed with interrupted 3-0 Vicryl.  The skin was closed with skin staples.  There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself.  The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors.  The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples.  The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened.  The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well.",Skull Base Reconstruction,Neurology,"neurology, rectus abdominis myocutaneous, skull base defect, squamous cell carcinoma, skull base, squamous cell, rectus sheath, abdominis, muscle, rectus, sheath"
Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia.,"PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.",Low-Transverse C-Section & BTL,Obstetrics / Gynecology,"obstetrics / gynecology, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine,"
Patient with palpitations and rcent worsening of chronic chest discomfort.,"CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.",Chest discomfort & palpitations - Consult.,Cardiovascular / Pulmonary,
Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,"PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.",Arthroscopic Rotator Cuff Repair,Orthopedic,
"The thoracic spine was examined in the AP, lateral and swimmer's projections.","EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.",MRI T-Spine - 1,Neurology,"neurology, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine,"
Follow up update on patient with left carotid angioplasty and stent placement.,"Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,",Cardiology - Letter,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Psychiatric Consultation of patient with anxiety.,"REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  ""I felt anxious yesterday."",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with ""syncopal episodes.""  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.",Psych Consult - Anxiety,Psychiatry / Psychology,
"Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.","TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.",CABG,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.,"PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.",Tonsillectomy,ENT - Otolaryngology,"ent - otolaryngology, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa"
"Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.","EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.",Chest Pulmonary Angio,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio"
"Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.","PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.",Esophagogastroduodenoscopy - 7,Gastroenterology,"gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach"
"A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study.","REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.",EMG/Nerve Conduction Study - 8,Neurology,"neurology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction"
"Esophagogastroduodenoscopy with biopsy.  Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.","TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:,  Abdominal pain.,POSTOPERATIVE DIAGNOSIS:,  Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS:  ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum.  Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION:  ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.",EGD with Biopsy - 2,Gastroenterology,"gastroenterology, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,"
"A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.","REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",New Onset Seizure,Pediatrics - Neonatal,
Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,"PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.",Cardiac Catheterization - 13,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery,"
Laparoscopic right radical nephrectomy due to right renal mass.,"PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.",Nephrectomy - Radical (Laparoscopic),Nephrology,"nephrology, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal,"
"Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.  Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.","PREOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,3.  Endometrial polyp.,4.  Right ovarian cyst.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,3.  Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in December of 2002.  She has subsequently been on tamoxifen.  Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst.  The above procedures were therefore performed.,FINDINGS:  ,On bimanual exam, the uterus was found to be slightly enlarged and anteverted.  The external genitalia was normal.  Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium.  Laparoscopic findings revealed a normal-appearing uterus and normal left ovary.  There was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum.  There was a cyst on the right ovary which appeared simple in nature.  The cyst was aspirated and the fluid was blood tinged.  Therefore, the decision to perform oophorectomy was made.  The liver margins appeared normal and there were no pelvic or abdominal adhesions noted.  The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position.  Her bladder was drained with a red Robinson catheter.  A bimanual exam was performed, which revealed the above findings.  A weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum.  The cervix was then sounded in the anteverted position to 10 cm.  The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10.  The hysteroscope was then inserted and the above findings were noted.  A sharp curette was then introduced and the 4 cm polyp was removed.  The hysteroscope was then reinserted and the polyp was found to be completely removed at this point.  The polyp was sent to Pathology for evaluation.  The uterine elevator was then placed as a means to manipulate the uterus.  The weighted speculum was removed.  Gloves were changed.  Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty.  Using a sterile saline drop test, appropriate placement was confirmed.  The abdomen was then insufflated with appropriate volume inflow of CO2.  The #11 step trocar was placed without difficulty.  The above findings were then visualized.  A 5 mm port was placed 2 cm above the pubic symphysis.  This was done under direct visualization and the grasper was inserted through this port for better visualization.  A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo-GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament.  Prior to this, the cyst was aspirated using 60 cc syringe on a needle.  Approximately, 20 cc of blood-tinged fluid was obtained.  After the ovary and fallopian tube were completely transected, this was placed in an EndoCatch bag and removed through the lateral port site.  The incision was found to be hemostatic.  The area was suction irrigated.  After adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated.  The infraumbilical port site and laparoscope were also removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  10 cc of 0.25% Marcaine was then injected locally.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  She will be followed up on an outpatient basis.",Hysteroscopy & Laproscopy with Salpingooophorectomy,Obstetrics / Gynecology,"obstetrics / gynecology, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium,"
"Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.","PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.",Microlaryngoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,"
Chronic cholecystitis without cholelithiasis.,"PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.",Laparoscopic Cholecystectomy - 3,Gastroenterology,"gastroenterology, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic"
Diagnostic fiberoptic bronchoscopy.,"PROCEDURE:,  Diagnostic fiberoptic bronchoscopy.,ANESTHESIA:  ,  Plain lidocaine 2% was given intrabronchially for local anesthesia.,PREOPERATIVE MEDICATIONS:,  ,1.  Lortab (10 mg) plus Phenergan (25 mg), p.o.  1 hour before the procedure.,2.  Versed a total of 5 mg given IV push during the procedure.,INDICATIONS: ,",Bronchoscopy - 8,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,"
Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.",CT Abdomen & Pelvis - 6,Nephrology,"nephrology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct"
Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura.,"PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.",Hematoma Evacuation,Neurosurgery,
MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.,"CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and ""equally reactive to light."" Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.",MRI Brain - Toxoplasmosis,Neurology,
"Acute renal failure, suspected, likely due to multi-organ system failure syndrome.","REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.",Renal Failure - Consult,Nephrology,
"Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.","PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.",Bunionectomy & Flexor Tenotomy,Orthopedic,"orthopedic, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon,"
Insertion of a #8 Shiley tracheostomy tube.  A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.,"OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,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, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.  The 2nd tracheal ring was identified.  Next, a #11-blade scalpel was used to make a trap door in the trachea.  The endotracheal tube was backed out.  A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit.  We then secured it in place using 0 silk suture.  A sterile dressing was applied.  The patient tolerated the procedure well.",Shiley Tracheostomy Tube Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,"
Left endoscopic carpal tunnel release and endotracheal fasciotomy.,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1.  Left endoscopic carpal tunnel release.,2.  Endotracheal fasciotomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management.  All risks and benefits were explained.  Questions answered.  Options discussed.  No guarantees were made.  She wished to proceed with surgery.,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.",Carpal Tunnel Release - 2,Orthopedic,"orthopedic, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament"
MRI of lumbar spine without contrast to evaluate chronic back pain.,"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.",MRI of Lumbar Spine w/o Contrast,Neurology,"neurology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine"
Transplant nephrectomy after rejection of renal transplant,"PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.",Nephrectomy - Transplant,Nephrology,"nephrology, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney,"
"Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.","PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.",Arthroplasty,Orthopedic,"orthopedic, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion"
Headache and diplopia.,"CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were ""unremarkable."" Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved.",Granulomatous Inflammation,Neurology,
"Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.","PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.",Cardiac Catheterization - 6,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous"
"Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.","REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.",High PT-INR - ER Visit,Cardiovascular / Pulmonary,
Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux.,"ADMITTING DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux.  Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia.  Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals.  He is also having reflux symptoms again.  He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure.  He was stable at that time.  He did complain of some nausea.  However, he did not have any vomiting at that time.  He had an NG tube in and was n.p.o.  He also had a PCA for pain management as well as Toradol.  On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed.  Over the next several days, his hospital course proceeded as follows.  He continued to complain of some nausea; however, he did not ever have any vomiting.  Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications.  He ambulated frequently.  He remained n.p.o. for three days.  He also had the NG tube in during that time.  On postoperative day #4, he began to have some flatus, and the NG tube was discontinued.  He was advanced to a liquid diet and tolerated this without any complications.  At this time, he was still using the PCA for pain control.  However, he was using it much less frequently than on days #1 and #2 postoperatively.  After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA.  The PCA was discontinued.  He tolerated the soft diet without any complications and continued to have flatus frequently.  On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications.  His pain was well controlled with p.o. pain medications.  He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:,  Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet.  It was also recommended that he does not drink any soda postoperatively.  He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting.  He will be able to attend school when it starts in a few weeks.  However, he is not going to be able to play football in the near future.  He was given prescription for pain medication upon discharge.  He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.",Discharge Summary - 10,Gastroenterology,"gastroenterology,"
"Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.","PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.",Lumbar Discogram,Orthopedic,"orthopedic, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
Ultrasound BPP - Advanced maternal age and hypertension.,"HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.",Biophysical Profile - 1,Obstetrics / Gynecology,"obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,"
MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.,"CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.",MRI T-Spine - Spinal Mets,Radiology,
"Diagnostic laparoscopy.   Acute pelvic inflammatory disease and periappendicitis.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.","PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:,  Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:,  None.,CULTURES:,  Intra-abdominally are done.,HISTORY:  ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room.  The pain has started in the umbilical area and radiated to McBurney's point.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  The patient was seen by Dr. Y at my request in the ER with me in attendance.  We went over the case.  He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  The patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  The patient has had hospitalization for this.  The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  All questions were answered.  ,PROCEDURE: ,The patient was seen in the Emergency Room.  In the Emergency Room, there is really no apparent vaginal discharge.  No odor or cervical motion tenderness.  Negative bladder sweep.  Adnexa were without abnormalities.  In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  The patient had no adnexal fullness.  The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  The both fallopian tubes were seen.  There did not appear to be hydrosalpinx.  The ovaries were seen.  The left showed some adhesions into the ovarian fossa.  The cul-de-sac had a banded adhesions.  The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  The patient's bowel was otherwise unremarkable.  The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID.  The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left.  The patient's case was turned over to him.  Dr. Y was performed an appendectomy following which cultures and copious irrigation.  Dr. Y was then closed the case.  The patient was placed on antibiotics.  We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1.  Periappendicitis.,2.  Pelvic inflammatory disease.,3.  Chronic adhesive disease.",Diagnostic Laparoscopy - 1,Obstetrics / Gynecology,"obstetrics / gynecology, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,"
Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.,"CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.",Lumbar Spine HNP - Consult,Orthopedic,
"Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.","PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",Anterior Cervical Discectomy & Fusion - 3,Neurosurgery,
Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,"CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a "" bulging disk"" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.",Back Pain - Discharge Summary,Orthopedic,
Mediastinal exploration and delayed primary chest closure.  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.,"TITLE OF OPERATION:,  Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:,  The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification.  The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma.  At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed.  The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy.  The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  The subcutaneous tissue and skin were closed in layers.  There was no evidence of significant increase in central venous pressure or desaturation.  The patient tolerated the procedure well.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.",Mediastinal Exploration,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest"
"Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.","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.",Subclavian Central Venous Catheter Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion"
"Primary low transverse cesarean section via Pfannenstiel incision.  Pregnancy at 40 weeks, failure to progress, premature prolonged rupture of membranes, group B strep colonization, and delivery of viable male neonate.","PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1.  Pregnancy at 40 weeks.,2.  Failure to progress.,3.  Premature prolonged rupture of membranes.,4.  Group B strep colonization.,5.  Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:,  500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS:  ,Normal appearing uterus, tubes, and ovaries.  A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively.  Infant weight equaled to 4140 gm with clear amniotic fluid.  The umbilical cord was wrapped around the leg tightly x1.  Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE:  ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy.  She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery.  The patient had a positive group beta strep colonization culture and was started on penicillin.  The patient was also started on Pitocin protocol at that time.  The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor.  IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units.  The patient was given a rest from the Pitocin.  She walked and had a short shower.  The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions.  Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position.  At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound.  Options were discussed with the patient and family and it was determined that we will take her for C-section today.  Consent was signed.  All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed.  She was placed in the dorsal supine position with left upward tilt.  She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate.  A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel.  The fascia was incised in the midline and extended laterally using curved Mayo scissors.  The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles.  Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle.  The rectus muscle was separated in the midline bluntly.  The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors.  The peritoneum was then bluntly stretched.  The bladder blade was placed.  The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors.  The incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted in the lower uterine segment.  A low transverse uterine incision was made with a second scalpel.  The uterine incision was extended laterally bluntly.  The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum.  Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically.  There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut.  Infant was handed to the waiting pediatrician.  Cord gas was sent for pH as well as blood typing.  The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris.  The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion.  A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis.  The uterus was returned to the abdomen.  The gutters were cleared of all clots and debris.  The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion.  The fascia was reapproximated with #0-Vicryl suture in a running fashion.  The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut.  The skin was then closed with staples.  The incision was dressed with sterile dressing and bandage.  Blood clots were evacuated from the vagina.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The mother was taken to the recovery room in stable and satisfactory condition.",Low-Transverse C-Section - 6,Obstetrics / Gynecology,"obstetrics / gynecology, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia,"
Holter monitoring for syncope.  Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.,"INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  No significant pauses noted.",Holter Monitor Report - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE"
Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.,"PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.",Anterior Cervical Discectomy,Orthopedic,
Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.",Chest Closure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation"
Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.,"PREOPERATIVE DIAGNOSIS:  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:,  ,1.  Left carpal tunnel syndrome.,2.  de Quervain's tenosynovitis.,OPERATIONS PERFORMED:  ,1.  Endoscopic carpal tunnel release.,2.  de Quervain's release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:  ,ENDOSCOPIC CARPAL TUNNEL RELEASE:,  With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated to 290 mm/Hg.  A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel.  Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field.  The first dorsal tunnel was then identified.  The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release).  EPB and APL tendons were inspected and found to be completely free.  The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position.  The tourniquet was deflated.  The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.",Endoscopic Carpal Tunnel & de Quervain's Release,Orthopedic,"orthopedic, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic,"
Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.,"TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.",Pituitary Tumor Resection,Neurosurgery,"neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,"
Patient presents with complaint of lump in the upper outer quadrant of the right breast,"CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.",Consult - Breast Cancer,Hematology - Oncology,
"Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.","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.",Thoracoscopy/Thoracotomy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,"
"Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.","HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.",Neurologic Consultation - 5,Neurology,
"Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.","REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:",Consult - Coronary Artery Disease,Cardiovascular / Pulmonary,
"Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.","PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.",Needle Localized Excision - Breast Neoplasm,Hematology - Oncology,"hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast"
"Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.","CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9"", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",Knee DJD - Consult,Orthopedic,
"Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.","PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.",Epidural Hematoma Evacuation,Neurology,"neurology, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia,"
Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).  She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,"REASON FOR VISIT:,  Six-month follow-up visit for paroxysmal atrial fibrillation (PAF).,She reports that she is getting occasional chest pains with activity.  Sometimes she feels that at night when she is lying in bed and it concerns her.,She is frustrated by her inability to lose weight even though she is hyperthyroid.,MEDICATIONS: , Tapazole 10 mg b.i.d., atenolol/chlorthalidone 50/25 mg b.i.d., Micro-K 10 mEq q.d., Lanoxin 0.125 mg q.d., spironolactone 25 mg q.d., Crestor 10 mg q.h.s., famotidine 20 mg, Bayer Aspirin 81 mg q.d., Vicodin p.r.n., and Nexium 40 mg-given samples of this today.,REVIEW OF SYSTEMS:,  No palpitations.  No lightheadedness or presyncope.  She is having mild pedal edema, but she drinks a lot of fluid.,PEX: , BP:  112/74.  PR:  70.  WT:  223 pounds (up three pounds).  Cardiac:  Regular rate and rhythm with a 1/6 murmur at the upper sternal border.  Chest:  Nontender.  Lungs:  Clear.  Abdomen:  Moderately overweight.  Extremities:  Trace edema.,EKG: , Sinus bradycardia at 58 beats per minute, mild inferolateral ST abnormalities.,IMPRESSION:,1.  Chest pain-Mild.  Her EKG is mildly abnormal.  Her last stress echo was in 2001.  I am going to have her return for one just to make sure it is nothing serious.  I suspect; however, that is more likely due to her weight and acid reflux.  I gave her samples of Nexium.,2.  Mild pedal edema-Has to cut down on fluid intake, weight loss will help as well, continue with the chlorthalidone.,3.  PAF-Due to hypertension, hyperthyroidism and hypokalemia.  Staying in sinus rhythm.,4.  Hyperthyroidism-Last TSH was mildly suppressed, she had been out of her Tapazole for a while, now back on it.,5.  Dyslipidemia-Samples of Crestor given.,6.  LVH.,7.  Menometrorrhagia.,PLAN:,1.  Return for stress echo.,2.  Reduce the fluid intake to help with pedal edema.,3.  Nexium trial.",PAF - 6-Month Followup,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, atrial fibrillation, ekg, paroxysmal atrial fibrillation, chest pains, pedal edema, hyperthyroidism, paf, atrial,"
"Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.","PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.",Cauterization - Epistaxis,ENT - Otolaryngology,"ent - otolaryngology, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,"
Right pleural effusion and suspected malignant mesothelioma.,"PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.",Mesothelioma - Pleural Biopsy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,"
Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.,"PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.",Pacemaker (Dual Chamber) - 1,Cardiovascular / Pulmonary,
"Echocardiographic Examination Report.   Angina and coronary artery disease.  Mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%, mild mitral regurgitation, diastolic dysfunction grade 2, mild pulmonary hypertension.","REASON FOR EXAM:,1.  Angina.,2.  Coronary artery disease.,INTERPRETATION:  ,This is a technically acceptable study.,DIMENSIONS:  ,Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  The left atrium is 3.9.,FINDINGS:  ,  Left atrium was mildly to moderately dilated.  No masses or thrombi were seen.  The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  The EF was moderately reduced with estimated EF of 40% with near normal thickening.  The right atrium was mildly dilated.  The right ventricle was normal in size.,Mitral valve showed to be structurally normal with no prolapse or vegetation.  There was mild mitral regurgitation on color flow interrogation.  The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  The aortic valve appeared to be structurally normal.  Normal peak velocity.  No significant AI.  Pulmonic valve showed mild PI.  Tricuspid valve showed mild tricuspid regurgitation.  Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg.  Anterior septum appeared to be intact.  No pericardial effusion was seen.,CONCLUSION:,1.  Mild biatrial enlargement.,2.  Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%.,3.  Mild mitral regurgitation.,4.  Diastolic dysfunction grade 2.,5.  Mild pulmonary hypertension.",Echocardiogram - 3,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, angina, coronary artery disease, septal, ventricular, diastolic, systolic, pulmonary hypertension, mitral regurgitation, septum, tricuspid, thickening, dysfunction, wall, ef, regurgitation, atrium, valve, dilated, mitral, ventricle, mildly,"
"Followup left-sided rotator cuff tear and cervical spinal stenosis.  Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.","REASON FOR VISIT: , Followup left-sided rotator cuff tear and cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: , Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy.  I had last seen her on 06/21/07.,At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy.  She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07.  At our last visit, I only had a report of her prior cervical spine MRI.  I did not have any recent images.  I referred her for cervical spine MRI and she returns today.,She states that her symptoms are unchanged.  She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y.,She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist.  She has some associated minimal weakness described in detail in our prior office note.  No significant right upper extremity symptoms.  No bowel, bladder dysfunction.  No difficulty with ambulation.,FINDINGS: , On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact.  Biceps and brachioradialis reflexes are 1 plus.  Hoffmann sign normal bilaterally.  Motor strength is 5 out of 5 in all muscle groups in lower extremities.  Hawkins and Neer impingement signs are positive at the left shoulder.,An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,Cervical spine MRI dated 06/28/07 is reviewed.  It is relatively limited study due to artifact.  He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change.  There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,I agree with the plan to go ahead and continue with rotator cuff surgery.  With regard to the radiculopathy, I believe this can be treated non-operatively to begin with.  I am referring her for consideration of cervical epidural steroid injections.  The improvement in her pain may help her recover better from the shoulder surgery.,I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks.",Rotator Cuff Tear,Neurology,"neurology, upper extremity, radiculopathy, rotator cuff repair, cervical spinal stenosis, rotator cuff tear, physical examination, cuff, impingement, stenosis, extremity, surgery, tear, shoulder, rotator, cervical,"
"Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.","PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.","Heart Catheterization, Ventriculography, & Angiography - 16",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography"
"Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.  Right lateral base of tongue lesion, probable cancer.","PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.",Tongue Lesion Biopsy,Hematology - Oncology,"hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy,"
Anterior cervical discectomy with decompression of spinal cord.  Anterior cervical fusion.  Anterior cervical instrumentation.  Insertion of intervertebral device.  Use of operating microscope.,"PREOPERATIVE DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS:  ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1.  Anterior cervical discectomy with decompression of spinal cord C7-T1.,2.  Anterior cervical fusion, C7-T1.,3.  Anterior cervical instrumentation, anterior C7-T1.,4.  Insertion of intervertebral device, C7-T1.,5.  Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,A 30 mL.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service.  He was placed in the supine position on an OR table.  His arms were carefully taped down.  He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck.  Subcutaneous tissue was dissected down to the level of the platysma.  The platysma was incised using electrocautery.  Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle.  This allowed us to get right down on to the anterior cervical spine.  Blunt dissection was done to sweep off the longus colli.  We isolated the C7-T1 interspace.  An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins.  This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur.  At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr.  The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur.  Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur.  At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace.  Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1.  An x-ray was taken.  It showed good placement of the plate and screws.,A deep drain was placed.  The platysma layer was closed in running fashion using #1 Vicryl.  Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl.  Skin was closed in a running fashion using 4-0 Monocryl.  Steri-Strips and dressings were applied.  All counts were correct.  There were no complications.",Anterior Cervical Discectomy & Fusion - 6,Neurosurgery,"neurosurgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,"
"Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.","PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.",Laryngoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,"
"Closed reduction percutaneous pinning, left distal humerus.   Closed type-III supracondylar fracture, left distal humerus.  Tethered brachial artery, left elbow.","PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1.  Closed type-III supracondylar fracture, left distal humerus.,2.  Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital.  A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS:  ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing.  He apparently had not had previous problems with his left arm.  He was seen in the Emergency with a grossly deformed left elbow.  His parents' were both present preoperatively.  His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region.  Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible.  He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department.  Closed reduction was accomplished in a sequential manner.  Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly.  Then a slow longitudinal traction was carried out.  The elbow was hyperflexed.  Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve.  The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally.  Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital.  He had scrubbed in to the case to follow up on the loss of the radial artery distally.  This was not present palpatory, but also by Doppler.  A weak ulnar artery pulse was present via Doppler.  Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______.  A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery.  Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this.  I then came back in and then we proceeded.  He was prepped and draped in the usual sterile manner.  Please see Dr. X's report for the discussion of the exploration and release of the brachial artery.  There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally.  Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure.  Steri-Strips were placed.  The patient's arm was placed in just a slight degree of flexion with a neutral position.  He was splinted posteriorly.  Adaptic and fluffs have been placed around the patient's pin sites.  K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above.  There is concern for growth plate disturbance.  He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning.  There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.",Closed Reduction Percutaneous Pinning,Orthopedic,"orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow,"
Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.,"PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.",Chest Closure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation"
Bilateral myringotomies with insertion of Santa Barbara T-tube.,"PREOPERATIVE DIAGNOSES:  ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:,  The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes.  At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction.  There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established.  The right ear was draped in normal sterile fashion.  Cerumen was removed from the external canal.  The extruding Santa Barbara T-tube was identified and atraumatically removed.  A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified.  With a mask anesthetic, the eardrum elevated.  A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated.  A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied.  Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.",Myringotomy/Tube Insertion - 2,ENT - Otolaryngology,"ent - otolaryngology, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic"
Pain management sample progress note.,"DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.",Pain Management Progress Note,Orthopedic,"orthopedic, progress note, management, muscle"
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.,"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.",Air Under Diaphragm - Consult,Gastroenterology,
Twin pregnancy with threatened preterm labor.,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:",Ultrasound OB - 4,Radiology,
The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.,"Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ and symmetrical.  Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation.  She is suffering from ongoing myofascitis.  Her treatment plan will consist of a series of trigger point injections, which were performed today.  She tolerated the procedure well.  I have asked her to ice the region intermittently for 15 minutes off and on x 3.  She will be followed in four weeks' time for repeat trigger point injections if indicated.,",Ortho Office Visit,Orthopedic,"orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental."
Pediatric Gastroenterology - Rectal Bleeding Consult.,"HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.",Rectal Bleeding - 1-year-old,Pediatrics - Neonatal,
Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.  Herniated nucleus pulposus of L5-S1 on the left.,"PREOPERATIVE DIAGNOSIS:,  Herniated nucleus pulposus of L5-S1 on the left.,POSTOPERATIVE DIAGNOSIS: ,Herniated nucleus pulposus of L5-S1 on the left.,PROCEDURE PERFORMED:, Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,SPECIMENS: , Disc that was not sent to the lab.,DRAINS: , None.,COMPLICATIONS: , None.,SURGICAL PROGNOSIS: , Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally.,SURGICAL INDICATIONS: , The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months.  The symptoms were unrelieved by conservative modalities.  The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors.  She is understanding the risks, benefits, potential complications, as well as all treatment alternatives.  She wished to proceed with the aforementioned surgery due to her persistent symptoms.  Informed consent was obtained.,OPERATIVE TECHNIQUE: , The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia.  She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position.  Palpation did reveal the iliac crest and suspected L5-S1 interspace.  Thereafter the lumbar spine was serially prepped and draped.  A midline incision was carried over the spinal process of L5 to S1.  Skin and subcutaneous tissue were divided sharply.  Electrocautery provided hemostasis.  Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia.  Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace.  On the left side, superior aspect dissection was carried out with the Cobb elevator and electrocautery.  This revealed the interspace of suspect level of L5-S1 on the left.  A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1.  X-ray did confirm the L5-S1 interval.  Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina.  Meticulous dissection was undertaken and the ligamentum flavum was removed.  Laminotomy was created with Kerrison rongeur, both proximally and distally.  The microscope was positioned and the dura was inspected.  A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left.  It was noted to be tented over a disc extrusion.  The nerve root was protected and medialized.  It was retracted with a nerve root retractor.  This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area.  A #15 Bard-Parker blade was utilized to create an annulotomy.  Medially, disc material was extruding through this annulotomy.  Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace.  Additional disc material was then removed, both to the right and left of the annulotomy.  Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces.  Once this was completed, the wound was copiously irrigated with antibiotic solution and suctioned dry.  The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level.  Nerve root was again expected exhibiting the foramina.  A foraminotomy was created with a Kerrison rongeur.  Once this was created, the nerve root was again inspected and deemed free of tension.  It was mobile within the neural foramina.  The wound was again copiously irrigated with antibiotic solution and suctioned dry.  A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura.  Lumbar fascia was then approximated with #1 Vicryl interrupted fashion, subcutaneous tissue with #2-0 Vicryl interrupted fashion, and #4-0 undyed Vicryl was utilized to approximate the skin.  Compression dressing was applied.  The patient was turned, awoken, and noted to be moving all four extremities without apparent deficits.  She was taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications.",Lumbar Laminotomy & Discectomy,Neurosurgery,"neurosurgery, lumbar laminotomy with discectomy, microscopic assisted, herniated nucleus pulposus, subcutaneous tissue, ligamentum flavum, kerrison rongeur, penfield elevator, lumbar laminotomy, lumbar fascia, nerve root, discectomy, lumbar, laminotomy, herniated,"
Transesophageal echocardiogram for aortic stenosis.  Normal left ventricular size and function.  Benign Doppler flow pattern.   Doppler study essentially benign.  Aorta essentially benign.  Atrial septum intact.  Study was negative.,"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,",Transesophageal Echocardiogram - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves"
"Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.","CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.",Consult - Seizures - 2,Neurology,
"Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.","PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.","Arthroscopy, Meniscoplasty, & Chondroplasty",Orthopedic,"orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral"
Normal awake and drowsy (stage I sleep) EEG for patient's age.,"DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.",Electroencephalogram,Neurology,"neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity"
MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.,"EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.",MRI of Brain w/o Contrast.,Neurology,"neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast,"
"The patient comes for three-week postpartum checkup, complaining of allergies.","CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.",Three-Week Postpartum Checkup,Obstetrics / Gynecology,"obstetrics / gynecology, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,"
Laparoscopic cholecystectomy.  Gallstone pancreatitis.  Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.,"PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS:  ,None.,OPERATIVE FINDINGS: , Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.  These dense adhesions were associated with chronic inflammatory edematous changes.  The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally.  The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally.  The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver.  There was no evidence of adhesions from the abdominal wall to the liver.  The remainder of the abdomen was unremarkable.,BRIEF HISTORY:  ,This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain.  She had been asked to follow up and scheduled for surgery previously.  Her pain had now been intractable associated with anorexia.  She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination.  Her transaminases were markedly elevated.  She also developed pancreatitis secondary to gallstones.  Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis.  She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis.  Following this, she was scheduled for operative laparoscopic cholecystectomy.  Her parents were explained the risks, benefits, and complications of the procedure.  She gave us informed consent to proceed with surgery.,OPERATIVE PROCEDURE:  ,The patient brought to the operative suite and placed in the supine position.  Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created.  Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty.  Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty.  The abdomen was then insufflated to 15 mmHg with carbon-dioxide.  Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty.  Video laparoscope was inserted and the above notable findings were identified in the operative findings.  The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed.  A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline.  The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament.  Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line.  These were inserted without difficulty.  The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder.  Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions.  Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct.  A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch.  This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place.  Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly.  Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor.,Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall.  The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery.  The abdomen was then irrigated with copious amounts of normal saline.  The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port.  There was noted to be gallstones within the gallbladder.  Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall.  Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty.  The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia.  A #4-0 Vicryl suture was used to approximate all incisions.  The incisions were then injected with local injectable 0.25% Marcaine.  All ports were then cleaned dry.  Steri-Strips were placed across and sterile pressure dressings were placed on top of this.  The patient tolerated the entire procedure well.  She was transferred to the Postanesthesia Care Unit in stable condition.  She will be followed closely in the postoperative course in General Medical Floor.",Cholecystectomy Laparoscopic,Gastroenterology,"gastroenterology, gallstone, gallbladder, pancreatitis, anterior abdominal wall, video laparoscope, laparoscopic cholecystectomy, omental adhesions, veress needle, cystic duct, injectable, adhesions, cholecystectomy, laparoscopic, abdomen"