description,transcription,sample_name,medical_specialty,keywords
Laparoscopic right partial nephrectomy due to right renal mass.,"PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.",Nephrectomy - Partial (Laparoscopic ),Nephrology,"nephrology, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal,"
"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,
Exercise myocardial perfusion study.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%,"CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.",Exercise Myocardial Perfusion Study,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia,"
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,
"Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.","REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says ""things have changed"".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.",Chest Pain - Cardiac Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest,"
"Right axillary adenopathy, thrombocytopenia, and hepatosplenomegaly.  Right axillary lymph node biopsy.","PREOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,POSTOPERATIVE DIAGNOSES:,1.  Right axillary adenopathy.,2.  Thrombocytopenia.,3.  Hepatosplenomegaly.,PROCEDURE PERFORMED:  ,Right axillary lymph node biopsy.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to the recovery room in stable condition.,BRIEF HISTORY:  ,The patient is a 37-year-old male who presented to ABCD General Hospital secondary to hiccups and was ultimately found to have a right axillary mass to be severely thrombocytopenic with a platelet count of 2000 as well as having hepatosplenomegaly.  The working diagnosis is lymphoma, however, the Hematology and Oncology Departments were requesting a lymph node biopsy in order to confirm the diagnosis as well as prognosis.  Thus, the patient was scheduled for a lymph node biopsy with platelets running secondary to thrombocytopenia at the time of surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a large right axillary lymphadenopathy, one of the lymph node was sent down as a fresh specimen.,PROCEDURE:  ,After informed written consent, risks and benefits of this procedure were explained to the patient.  The patient was brought to the operating suite, prepped and draped in a normal sterile fashion.  Multiple lymph nodes were palpated in the right axilla, however, the most inferior node was to be removed.  First, the skin was anesthetized with 1% lidocaine solution.  Next, using a #15 blade scalpel, an incision was made approximately 4 cm in length transversally in the inferior axilla.  Next, using electro Bovie cautery, maintaining hemostasis, dissection was carried down to the lymph node.  The lymph node was then completely excised using electro Bovie cautery as well as hemostats to maintain hemostasis and then lymph node was sent to specimen fresh to the lab.  Several hemostats were used, suture ligated with #3-0 Vicryl suture and hemostasis was maintained.  Next the deep dermal layers were approximated with #3-0 Vicryl suture.  After the wound has been copiously irrigated, the skin was closed with running subcuticular #4-0 undyed Vicryl suture and the pathology is pending.  The patient did tolerated the procedure well.  Steri-Strips and sterile dressings were applied and the patient was transferred to the Recovery in stable condition.",Biopsy - Axillary Lymph Node,Hematology - Oncology,"hematology - oncology, hepatosplenomegaly, thrombocytopenia, axillary adenopathy, axillary lymph node biopsy, axillary lymph node, lymph node biopsy, lymph node, lymph, node, axillary, adenopathy, hemostasis, suture, biopsy,"
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,
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,
Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.   Vertebroplasties at T7 and T9 with insertion of prosthetic device.   Fracture of the T8 vertebra and T9 vertebra.,"PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.",Kyphoplasty & Vertebroplasty,Orthopedic,"orthopedic, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,"
"Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.","ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture ""wings."",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.",Ash Split Venous Port,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter"
"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,
Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.,"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.",Patent Ductus Arteriosus Ligation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation"
Normal cataract surgery.,"NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital.  Topical tetracaine drops were applied.  The operative eye was prepped and draped in the usual sterile fashion.  A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized.  A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  A 5- to 5.5-mm anterior capsulorrhexis was created.  The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  Peripheral cortex was removed with the irrigation and aspiration handpiece.  The posterior capsule was polished.  The capsular bag was expanded with viscoelastic.  The implant was inspected under the microscope and found to be free of defects.  The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  The trailing haptic was positioned with the cartridge system.  Residual viscoelastic was removed from the anterior chamber and from behind the implant.  The corneal wound was hydrated with balanced salt solution.  The anterior chamber was fully re-formed through the side-port incision.  The wound was inspected and found to be watertight.  The intraocular pressure was adjusted as necessary.  The lid speculum was removed.  Topical Timoptic drops, Eserine and Dexacidin ointment were applied.  The eye was shielded.  The patient appeared to tolerate the procedure well and left the operating room in stable condition.  Followup appointment is with Dr. X on the first postoperative day.",Cataract Surgery,Ophthalmology,"ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: 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.,"
Repair of upper lid canalicular laceration - Sample/Template.,"PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.",Lid Laceration Repair,Ophthalmology,"ophthalmology, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular"
KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.,"PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.",Kyphoplasty,Orthopedic,"orthopedic, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy"
Right carpal tunnel release.,"PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.",Carpal Tunnel Release - 1,Orthopedic,"orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,"
"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 - 2,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"
"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,Neurosurgery,"neurosurgery, 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"
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,
"Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.","SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.",COPD & Pneumonia - SOAP,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd"
"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,Neurology,"neurology, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,"
"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,
"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 - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,"
The patient with continued problems with her headaches.,"She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.",Headache - Office Visit,Neurology,"neurology, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran"
Transvaginal ultrasound to evaluate pelvic pain.,"EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.",Ultrasound - Transvaginal,Obstetrics / Gynecology,"obstetrics / gynecology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion,"
"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,Neurosurgery,"neurosurgery, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft"
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,"
Left medial compartment osteoarthritis of the knee.  Left unicompartmental knee replacement.,"PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:,  Left medial compartment osteoarthritis of the knee.,PROCEDURE  PERFORMED:,  Left unicompartmental knee replacement.,COMPONENTS USED:,  Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:,  None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side.  She has done quite well with this.  She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table.  After appropriate anesthesia, the left lower extremity was identified with a time out procedure.  Preoperative antibiotics were given.  Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet.  The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used.  Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed.  The anterior fat pad was removed.  The knee was then examined.  The ACL was found to be intact.  The lateral compartment had very minimal arthritis.  There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild.  Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place.  Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection.  Following this resection, the femoral intramedullary guide was placed without difficulty.  The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide.  Once in the appropriate position, it was pinned and drilled.  This was removed, and the posterior cutting block was inserted.  It was impacted into place.  Posterior bone cut was made for the medium femoral component.  Next, a zero spigot was used and the distal femur was reamed.  Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well.  Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit.  Next, the tibia was prepared.  The tibial tray was pinned into place, and the cuts for the keel of the tibia were made.  These were removed with a small osteotome from the set.  Following this, a trial tibial with the keel was placed and it did fit nicely.  After this, all trial components were removed.  The knee was copiously irrigated.  Cement was begun mixing.  Drill holes were used along the femur for cement interdigitation.  The wound was cleaned and dried.  Cement was placed on the tibia.  Tibial tray was impacted into place.  Excess cement was removed.  Tibia was placed in the femur.  Femoral component was impacted into place.  Excess cement was removed.  It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened.  Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size.  A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion.  The intramedullary rod removed from the femur.  The wound was irrigated with normal saline.  The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin.  A sterile dressing was placed.  Tourniquet was then desufflated.  Sponge and needle counts were correct at the end of the procedure.  Dr. Jinnah was present for the surgery.  The patient was transferred to the recovery room in stable condition.  She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis.  Prior to closure, the posterior capsule was injected with the joint cocktail.",Knee Replacement,Orthopedic,"orthopedic, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement,"
"Primary cesarean section by low-transverse incision.  Term pregnancy, nonreassuring fetal heart tracing.","PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.",Low-Transverse C-Section - 1,Obstetrics / Gynecology,"obstetrics / gynecology, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine,"
Tonsillectomy and adenoidectomy and Left superficial nasal cauterization.  Recurrent tonsillitis.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.  Residual adenoid hypertrophy and recurrent epistaxis.,"PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.",Tonsillectomy & Adenoidectomy - 4,ENT - Otolaryngology,"ent - otolaryngology, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy"
"Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.","PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding history of foot problems.  The problem has been progressive in nature.  The preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity.  The purpose of the surgery is to alleviate pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was given 1 g of Ancef IV for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  No tourniquet was utilized.  IV sedation was achieved followed by a local anesthetic consisting of approximately 10 mL total in 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:, Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.  A dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal.  Care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery.  The extensor tendon was identified and retracted medially.  Sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface.  Inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head.  An oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration.  The both edges were rasped smooth.,Attention was then focused on the fifth metatarsal.  The periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface.  An excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,Using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal.  Generous amounts of lateral cortex were preserved for the lateral hinge.  The wedge was removed from the surgical field.  The fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position.  Good purchase was noted at the osteotomy site.  Inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position.  The surgical site was flushed with copious amounts of normal saline irrigation.  The periosteal and capsular layers were closed with running sutures of 3-0 Vicryl.  The subcutaneous tissues were closed with 4-0 Vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion.  A dressing consisting of Adaptic, 4 x 4, confirming bandages, and ACE wrap to provide mild compression was applied.  The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,A walker boot was dispensed and applied.  The patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,Office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg one p.o. t.i.d. for 10 days and Ultram ER, #15 one p.o. daily along with written and oral home instructions including a number on which I can be reached 24 hours a day if any problem arises.,After short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.",Closing Wedge Osteotomy,Orthopedic,"orthopedic, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia"
"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,
"The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.","HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.",Cardiac Consultation - 7,Cardiovascular / Pulmonary,
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,"
"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 - 1",Cardiovascular / Pulmonary,"cardiovascular / pulmonary, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex,"
Generalized abdominal pain with swelling at the site of the ileostomy.  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.,"CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.",CT Abdomen & Pelvis - 9,Gastroenterology,"gastroenterology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,"
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 - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,"
"Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.","REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says ""things have changed"".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel ""like cramps"" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of ""falling"", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.",Chest Pain - Cardiac Consult,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest,"
Diagnostic Mammogram and ultrasound of the breast.,"EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast.  Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained.  Spot compression views of the palpable area were also obtained.  Right breast ultrasound was performed.  Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue.  No new mass or architectural distortion is evident.  Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged.  There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1.  Stable mammographic appearance from mm/dd/yy.,2.  No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality.  The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign",Diagnostic Mammogram,Obstetrics / Gynecology,"obstetrics / gynecology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable"
"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,
Left distal both-bone forearm fracture.  Closed reduction with splint application with use of image intensifier.,"PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:,  Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008.  Evaluation in the emergency department revealed both-bone forearm fracture.  Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was induced with propofol for conscious sedation via the emergency department staff.  After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  The patient was aroused from anesthesia and tolerated the procedure well.  Post-reduction plain films revealed some anterior displacement of the distal fragment.  At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement.  We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,",Closed Reduction - 2,Orthopedic,"orthopedic, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture"
"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,
Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome.,"ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted",Back & Leg Pain - Discharge Summary,Orthopedic,"orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg"
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,
"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,Neurosurgery,
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,
Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,"REASON FOR VISIT:,  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture.  The patient states that this pain is well controlled.  He has had no fevers, chills or night sweats.  He has had some mild drainage from his pin sites.  He just started doing range of motion type exercises for his right knee.  He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema.  There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted.  The patient had 3/5 strength in the EHL, FHL.  He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee.  It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee.  I would like to really work on this as he has not had much up to this time.  He should remain nonweightbearing.  I would like to have him return in 2 weeks' time to assess his knee range of motion.  He should not need x-rays at that time.",ORIF - Followup,Orthopedic,"orthopedic, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif,"
"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,
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,Neurology,"neurology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,"
"Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD.  Left ventriculogram and aortogram.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.","PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Cineangiography of SVG to OM.,4.  Cineangiography of LIMA to LAD.,5.  Left ventriculogram.,6.  Aortogram.,7.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:,  After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac catheterization suite.  The right groin was prepped in the usual sterile fashion.  Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta.  Next, Judkins left catheter was used to engage the left coronary system.  Cineangiography was recorded in multiple views.  Next, Judkins right catheter was used to engage the right coronary system.  Cineangiography was recorded in multiple views.  Next, the Judkins right catheter was used to engage the SVG to OM.  Cineangiography was recorded.  Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views.  Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressures were measured.  LV gram was done and a pullback gradient across the aortic valve was done and recorded.  Next, an aortogram was done and recorded.  At this point, I decided to proceed with percutaneous intervention of the left circumflex.  Therefore, AVA 3.5 guide was used to engage the left coronary artery.  Angiomax bolus and drip was started.  Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  We next attempted a cutting balloon.  Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire.  Again, we were unable to cross the lesion with the stent.  We then try to cross with a noncompliant balloon, which we were unsuccessful.  We also try to cutting balloon again, we were unsuccessful.  Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  Final images showed no evidence of dissection, perforation, or further complication.  The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1.  The LV.  LVEDP was 4.  LVES is approximately 50%-55% with inferobasal hypokinesis.  No significant MR. No gradient across the aortic valve.,2.  Aortogram.  The ascending aorta shows no significant dilatation or evidence of dissection.  The valve shows no significant aortic insufficiencies.  The abdominal aorta and distal aorta shows significant tortuosities.,3.  The left main.  The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4.  Left circumflex.  The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  LAD.  The LAD is a totally 100% occluded vessel.  The LIMA to LAD is patent with only a small-to-moderate caliber LAD.  There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%.  The diagonal shows proximal 80% stenosis.,6.  The right coronary artery:  The right coronary artery is 100% occluded.  There are retrograde collaterals from left to right to the distal PDA and PLV branches.  The SVG to OM is 100% occluded at its take off.  The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  Final images showed some improvement, however, continued residual stenosis.  At this point, the patient will be transferred back to telemetry floor and monitored.  We can attempt future intervention or continue aggressive medical management.  The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch.  Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.",Cineangiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,"
"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 - 2,Hematology - Oncology,
Carotid artery angiograms.,"PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,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 fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.",Bilateral Carotid Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,"
CT REPORT - Soft Tissue Neck,"FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space.,There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages.,There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding.,There is a 14 x 5 x 12 mm node involving the left submental region (Level I).,There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center.,There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node.,There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease.,There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy.,There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal.,IMPRESSION:,Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding.,Borderline enlargement of a submental node suggesting Level I adenopathy.,Bilateral deep cervical nodal disease involving bilateral Level II, Level III and left Level IV.",CT Neck - 1,Orthopedic,"orthopedic, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical"
"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,ENT - Otolaryngology,
"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,
"This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.","HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.",Wound Check - Status Post APR,Gastroenterology,"gastroenterology, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE"
"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,
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,"
"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,
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"
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,"
"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,
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,"
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"
"Colonoscopy, conscious sedation, and snare polypectomy.","PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS:  ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy.  ,INDICATIONS:  ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  He has had previous colonoscopy.  There is no family history of bleeding, no current problems with his bowels.  On examination, he has internal hemorrhoids.  His prostate is enlarged and increased somewhat in firmness.  He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  These were removed with snare polypectomy technique.  I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation.  Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  The scope was withdrawn into the left transverse colon, where the second polyp was identified.  It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  The scope was then gradually withdrawn the remaining distance and removed.  The patient tolerated the procedure well.",Colonoscopy & Polypectomy - 2,Gastroenterology,"gastroenterology, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy,"
"Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.","PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.",Angiogram & Angioplasty,Cardiovascular / Pulmonary,
"Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.","PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.",Exploratory Laparotomy - 1,Gastroenterology,"gastroenterology, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal"
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) - 5,Cardiovascular / Pulmonary,
"The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan.  The patient's subdural effusions are still noticeable, but they are improving.","REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008.  I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm.  The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm.  There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle.  He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.",CT Head - 2,Neurology,"neurology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,"
"Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.","PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.",Pacemaker Lead Placement & Rrevision.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular"
"Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.","MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 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 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  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 myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.",Myocardial Perfusion Imaging - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging,"
"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,
"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,
"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,Neurosurgery,"neurosurgery, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft,"
"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,
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,
"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,
Vitrectomy under local anesthesia.,"DESCRIPTION OF PROCEDURE:,  After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.",Vitrectomy - Local Anesthesia,Ophthalmology,"ophthalmology, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,"
Heidenhain variant of Creutzfeldt-Jakob Disease (CJD),"CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:,  CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).",Creutzfeldt-Jakob Disease,Neurology,
"Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.","PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.",Cystopyelogram,Nephrology,"nephrology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,"
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,Hematology - Oncology,"hematology - oncology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,"
"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.,6",Discharge Summary - Mesothelioma - 2,Hematology - Oncology,
"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,
"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,Cardiovascular / Pulmonary,
Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.,"EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.",Three Views - Ankle,Orthopedic,"orthopedic, three views, calcaneal, plantar, spur, osseous, ankle"
"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"
"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,
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,
"Lateral and plantar condylectomy, fifth left metatarsal.","TITLE OF OPERATION:,  Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA:  ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,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 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 a normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left 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 fifth left metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized.  The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved.  The bony prominences were removed and passed off the operating table to be sent to pathology for identification.  The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp.  The area was copiously flushed with saline.  Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively.  The incision was reinforced with Steri-Strips.  Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited.  The patient's left ankle tourniquet at this time 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 and the patient's left foot was placed in a surgical shoe.  The patient was then transferred to the recovery 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 medications and instructions on how to control her postoperative course.  She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.",Condylectomy,Orthopedic,"orthopedic, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,"
"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,
"Patient with chest pains, CAD, and cardiomyopathy.","INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:,  Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72.  Blood pressure decreased from 160/84 to 130/78.  The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test.  53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images are normal.  The post Persantine images show mildly decreased uptake in the septum.  The sum score is 0.,2.  The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1.  Mild septal ischemia.  Likely due to the left bundle-branch block.,2.  Mild cardiomyopathy, EF of 52%.,3.  Mild hypertension at 160/84.,4.  Left bundle-branch block.,",Cardiac Radionuclide Stress Test,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear"
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,Neurology,"neurology, 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,"
Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.,"PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.",Hysterectomy - Laparoscopic Supracervical,Obstetrics / Gynecology,"obstetrics / gynecology, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar"
"Carpal tunnel release.  Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.","PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.",Carpal Tunnel Release,Orthopedic,"orthopedic, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal,"
HCT: Subdural hemorrhage.,"CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.",CT Brain: Subdural Hemorrhage.,Neurology,"neurology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,"
"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,"
"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,
Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.,"PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.",Brain Stimulator Electrode,Neurology,"neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,"
A 19-year-old right-handed male injured in a motor vehicle accident.,"XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,",Ortho - Letter - 1,Orthopedic,"orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho,"
Insertion of transvenous pacemaker for tachybrady syndrome,"PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.",Pacemaker Insertion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion,"
"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,"
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,Orthopedic,"orthopedic, 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"
Patient is here to discuss possible open lung biopsy.,"CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.",Lung Biopsy Discussion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, 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.,"
Pediatric Gastroenterology - History of gagging.,"HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.",Gagging - 3-year-old,Gastroenterology,"gastroenterology, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,"
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,Gastroenterology,"gastroenterology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen"
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,
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,
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,Gastroenterology,"gastroenterology, colon cancer screening, loose stools, colorectal, colonoscopy,"
Trauma/ATV accident resulting in left open humerus fracture.,"ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:,  Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:,  None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008.  Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident.  He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters.  The patient denies any loss of consciousness.  He was not amnestic to the event.  He was taken by family members to the Iredell County Hospital, where he was initially evaluated.  Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture.  No other apparent injuries.  This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment.  The left upper extremity x-ray did demonstrate an open left distal humerus fracture.  The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture.  In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture.  In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures.  Throughout the duration of the procedure, the patient had a palpable distal radial pulse.  The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture.  A wound VAC was then placed over the wound at the conclusion of the procedure.  The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring.  His diet was advanced and his pain was controlled with pain medication.  The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident.  A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point.  Once his C spine had been cleared and the absence of a closed head injury was confirmed.  The patient was then transferred from the Intensive Care Unit to the General Floor bed.  His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound.  He again tolerated this procedure well on his return to the General Pediatrics Floor.  Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries.  However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity.  Moreover, the patient had no complaints of paresthesia.  There was no demonstration of pallor or pain on passive motion.  There was good capillary refill to the digits of the left hand.  By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well.  He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies.  He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2.  Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3.  Negative pressure wound dressing (July 23, 2008).,4.  Irrigation and debridement of left elbow fracture (July 26, 2008).,5.  CT of the brain without contrast (July 24, 2008).,DISPOSITION:  ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS:  ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity.  He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics.  Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.",Discharge Summary - ATV Accident,Orthopedic,"orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture,"
"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 - 9",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,Nephrology,
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,Radiology,
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."
"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,
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 - 3,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,"
"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,
"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,
Debridement left ischial ulcer.,"PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.",Ischial Ulcer Debridement,Gastroenterology,"gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer"
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 - 2,Psychiatry / Psychology,
"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 - 2,Neurology,
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,Nephrology,"nephrology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,"
Revision right total knee arthroplasty.  Right failed total knee arthroplasty.,"PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS:  ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: ,  Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes.  Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used.  A NexGen femoral component with a distal femoral augmented block, size 5 mm.  A NexGen tibial component, size 3 mm was used.  A size 14 mm constrained polyethylene surface was used as well.  Original patellar component that the patient had was maintained.,COMPLICATIONS:  ,None.,BRIEF HISTORY:,  The patient is a 68-year-old female with a history of knee pain for 13 years.  She had previous total knee arthroplasty and revision at an outside facility.  She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:,  The patient was taken to the operative suite and placed on the operating table.  Department of Anesthesia administered the spinal anesthetic.  Once adequately anesthetized, the patient was placed in a supine position.  Care was ensured and she was adequately secured and well padded in position.  Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was inflated to approximately 325 mmHg on the right thigh.  At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum.  A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface.  There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well.  At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed.  This was done without difficulty.  Attention was then directed removing the femoral component.  Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed.  After this was performed, attention was then directed to the tibial component.  An osteotome was again inserted around the surface and this was easily pried loose.  There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation.  This was evaluated.  The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component.  The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component.  At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut.  We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut.  We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12.  At this point, the distal femoral cutting guide based on the intramedullary head was then placed.  Care was ensured that this was aligned in proper rotation with the external epicondylar axis.  Once this was pinned in position, approximately a six degree valgus cut was then made.  This allowed a portion of the medial condyle to be removed distally.  The anterior cut was checked next using the intramedullary guide.  The anterior surface cutting block was then placed.  This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis.  Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made.  It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface.  _______ was then removed and the chamfer cutting guide was then placed on.  This allowed us to make a box cut and recut some of the angled cuts of the distal femur.  Once this was placed and pinned in position.  Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut.  It was noted that the anterior chamfers did not need to be cut, take off no bone.  The posterior chamfers did remove some bony aspects.  This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component.  After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed.  This appeared to have an adequate fit and then packed in position.  It appeared to be satisfactory.  At this point, this was removed and attention was then directed to the tibia.  The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained.  At this point, the intramedullary guide was used to evaluate a tibial cut.  This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface.  The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component.  At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone.  This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component.  This was placed in a proper position.  A 10 mm articular surface was placed in the knee and this was taken through range of motion.  This was found to have better alignment and satisfactory position.  We elected to take an intraoperative x-ray at this point, to evaluate our cut.  The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis.  At this point, all trials were removed.  The patella was then examined.  The rongeur was used to remove the surrounding synovium.  The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone.  It was elected at this time to maintain this anatomic patella that was previously placed.  At this point, the joint again was reevaluated and any bone loose fragments removed.  There was noted to be some posterior tightness and mild osteophytes.  These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes.  Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried.  The tourniquet was then reinflated.  The canals were prepped for cementing.  They were suction-dried and cleaned.  The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial.  Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component.  The stemmed femoral component was then impacted in position and cemented.  Again care was ensured that it was in adequate position and proper rotation.  A size 14 mm poly was then inserted in between to provide compression.  This was then taken through extension and held until cement cured.  This was then removed and the components were evaluated.  All excess cement was removed and they were well fixed.  Size 14 mm trial Poly was then placed and this was taken through range of motion.  This was found to have excellent range of motion and good stability.  It was elected at this time that we would go with the size 14 mm Poly.  This gave us extra Poly for ware and then provide excellent contact throughout the range of motion.  The final articular surface was then placed and tightened into position to allow to _______ secured.  The knee was then reduced and the knee was taken through range of motion.  The patella was tracking with no-touch technique and adequately positioned.  At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry.  All bleeding was cauterized using a Bovie cautery.  The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion.  This was reinforced with a running #2-0 Vicryl.  The knee was then flexed and noted that the patella was tracking with good alignment.  The wound was again copiously irrigated and suctioned dry.  A drain was placed prior to retinaculum repair deep to this to provide adequate drainage.  At this point, the subcutaneous tissue was closed with #2-0 Vicryl.  Skin was approximated with skin clips.  Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed.  A large Dupre dressing was then placed up the entire lower extremity.  The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.",Knee Arthroplasty - Revision,Orthopedic,"orthopedic, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial,"
"Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.","PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, 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.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.",EGD with Biopsy - 1,Gastroenterology,"gastroenterology, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,"
"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,
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 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,
"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 - 1,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"
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,
Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation.,"PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.",Laparoscopic Appendectomy - 4,Gastroenterology,"gastroenterology, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,"
"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,"
"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"
"Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.","PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.",Cesarean Section & BTL,Obstetrics / Gynecology,"obstetrics / gynecology, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine,"
"Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.","XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ  07018,Re:",Ortho - Letter - 2,Orthopedic,"orthopedic, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger,"
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,
Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.  Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,"PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.",Esophagogastroduodenoscopy - 9,Gastroenterology,"gastroenterology, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal"
The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty.  The patient has a history of back and buttock pain for some time.,"HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty.  The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time.  She was found to have an L5 compression fracture.  She was treated conservatively over several months, but did not improve.  Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing.  The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence.  She does complain of back pain.  She has been wearing a back brace and corset.  She does not have weakness.,PAST MEDICAL HISTORY:,  The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:,  She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally.  She is a widow.  She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL:  The patient is an elderly frail white female in no distress.  LUNGS:  Clear.  HEART:  Sounds are regular.  ABDOMEN:  She has a protuberant abdomen.  She has tenderness to palpation in the lumbosacral area.  Sciatic notch tenderness is not present.  Straight leg raise testing evokes back pain.  NEUROLOGICAL:  She is awake, alert, and oriented.  Speech is intact.  Comprehension is normal.  Strength is intact in the upper extremities.  She has giveaway strength in the lower extremities.  Reflexes are diminished at the knees and ankles.  Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture.  A CT scan has shown some healing of this fracture.  She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain.  She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments.  At this point, I believe the patient is a good candidate for L5 kyphoplasty.  I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery.  Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed.  The patient understands the issues involved.  She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.",Kyphoplasty - Consult,Orthopedic,"orthopedic, leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,"
"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,Neurology,"neurology, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,"
Tracheostomy with skin flaps and SCOOP procedure FastTract.  Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease.,"PREOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1.  Oxygen dependency.,2.  Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1.  Tracheostomy with skin flaps.,2.  SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:  ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home.  The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:,  The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position.  After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg.  The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch.  The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck.  After this, the patient was then prepped and draped with Hibiclens.  A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion.  After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties.  Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles.  The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified.  Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps.  The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed.  The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus.  Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization.  After this, the patient's anterior trachea was then identified and cleaned with pusher.  After this, the cricoid cartilage along the first and second tracheal rings was identified.  The cricoid hook was placed and the trachea was brought more anteriorly and superiorly.  After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker.  After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage.  After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap.  After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%.  The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition.  The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours.  The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.",Tracheostomy & SCOOP Procedure,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages"
Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.,"TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.",Patent Ductus Arteriosus Ligation,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation"
"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"
"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,
Heidenhain variant of Creutzfeldt-Jakob Disease (CJD),"CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:,  CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).",Creutzfeldt-Jakob Disease,Neurology,
"Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.","PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.",Total Abdominal Hysterectomy - 2,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum,"
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,
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,Neurosurgery,"neurosurgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior"
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,
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,"
Patient with sudden onset dizziness and RUE clumsiness.  Giant Left MCA Aneurysm.,"HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.",MCA Aneurysm,Neurology,"neurology, mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,"
"Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.","PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.",Femoral Artery Cannulation & Aortogram,Cardiovascular / Pulmonary,
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 - 1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretionsNOTE"
"Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion.  Dilatation and curettage and laparoscopy and injection of indigo carmine dye.","PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Pelvic pain.,3.  Infertility.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Infertility.,3.  Pelvic pain.,4.  Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy.,3.  Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile.  The cervix is nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum.  Uterus sounded to a depth of 10.5 cm.  Endocervical canal was progressively dilated with Hanks dilators to #20-French.  A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis.  A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air.  A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity.  The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted.  The laparoscope was then inserted through the trocar with visualization of the pelvic contents.  In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas.  The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria.  The ovaries also appeared normal bilaterally.  The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area.  An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still.  Both fallopian tubes apparently were blocked.  The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum.  The patient tolerated the procedure well.  Instruments were removed from the vaginal vault and the abdomen.  Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures.  Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.",D&C & Laparoscopy,Obstetrics / Gynecology,"obstetrics / gynecology, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,"
Electroencephalographic findings and interpretation,"HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.",Electroencephalography,Neurology,"neurology, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal,"
"Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.","ADMITTING DIAGNOSES:,1.  Leiomyosarcoma.,2.  History of pulmonary embolism.,3.  History of subdural hematoma.,4.  Pancytopenia.,5.  History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2.  CTA, chest PE study showing no evidence for pulmonary embolism.,3.  Head CT showing no evidence of acute intracranial abnormalities.,4.  Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007.  The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon.  MRI showed inflammation and was thought to be secondary to rheumatoid arthritis.  The mass increased in size.  She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive.  She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy.  She began treatment with CIVI-CAD in December 2007.  Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation.  She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1.  Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2.  History of pulmonary embolism.  Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain.  She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day.  She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3.  History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own.  Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities.  The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4.  Pancytopenia.  On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400.  The patient's counts were followed throughout admission.  She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet.  At discharge her ANC is back up to 1100 and she is taken off neutropenic diet.  Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5.  History of pneumonia.  During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP:  ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m.  The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.",Leiomyosarcoma,Hematology - Oncology,"hematology - oncology, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary,"
"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,
"Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.","PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.",Exploratory Laparotomy - 2,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis,"
"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,
"Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.","PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,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 the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.",I&D & Foreign Body Removal,Orthopedic,"orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot"
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,
"Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.","PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.",Axillary Dissection & Mass Excision,Hematology - Oncology,"hematology - oncology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,"
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 - 2,Hematology - Oncology,
"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,
"Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant.   Chronic pelvic pain, probably secondary to endometriosis.","PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:,  Mild pelvic endometriosis.,PROCEDURE:,1.  Attempted laparoscopy.,2.  Open laparoscopy.,3.  Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  A Hulka tenaculum was placed transcervically.  The other instruments were removed.  A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region.  Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum.  The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction.  The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken.  The skin incision was expanded with a knife blade.  Blunt dissection was used to carry the dissection down to the fascia.  This was grasped with Kocher clamps, entered sharply and opened transversely.  Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  The left tube and ovary were normal.  There were no adhesions.  There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated.  The smoke plume was removed without difficulty.  Approximately 50 mL of irrigant was left in the pelvis.  Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed.  The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly.  They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  The vaginal instruments were removed.  All counts were correct.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.",Laparoscopy - 3,Obstetrics / Gynecology,"obstetrics / gynecology, endometriosis, fulguration, endometrial, single tooth tenaculum, endometrial implant, hulka tenaculum, veress needle, hasson cannula, pneumoperitoneum, laparoscopy, cannula,"
"Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.","PREOPERATIVE DIAGNOSIS:,  Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  He had previously undergone a CT scan.  Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  The scalp was prepped and draped in the usual sterile fashion.  A previous incision was reopened and the scalp flap was reflected forward.  We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  We did explore laterally and saw a little bit of the mesh on the lateral orbit.  Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  We had achieved good hemostasis.  The wound was closed in multiple layers in usual fashion over a Blake drain.  At the end of the procedure, all sponge and needle counts were correct.  A sterile dressing was applied to the incision.  The patient was transported to the recovery room in good condition after having tolerated the procedure well.  I was personally present and scrubbed and performed/supervised all key portions.",Bifrontal Cranioplasty,Neurosurgery,"neurosurgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,"
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,
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,Nephrology,
"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,Neurology,"neurology, 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"
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,
A 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  Right ruptured ectopic pregnancy with hemoperitoneum.   Anemia secondary to blood loss.,"HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:,  The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst.  The patient was kept in observation for 24 hours.  The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac.  The patient was admitted to the hospital.  A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000.  The diagnosis of a possible ruptured ectopic pregnancy was established.  The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy.  The right salpingectomy was performed with no complications.  The patient received 2 units of red packed cells.  On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9.  Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery.  The hospital course was uneventful.  There was no fever reported.  The abdomen was soft.  She had a normal bowel movement.  The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1.  Right ruptured ectopic pregnancy with hemoperitoneum.,2.  Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.",Ectopic Pregnancy - Discharge Summary,Obstetrics / Gynecology,"obstetrics / gynecology, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,"
"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 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,
Insertion of central venous line and arterial line and transesophageal echocardiography probe.,"INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,",Central Venous & Arterial  Line,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter"
"Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.","CHIEF COMPLAINT:,  Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness.  She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  She is not able to describe what direction she feels like she is spinning.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.  She does note that it is worse when she turns to the right and when she turns to the left.  She also complains that she gets similar sensations when she looks up.  She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches.  She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1.  CHF (uses portable oxygen).,2.  Atrial fibrillation.,3.  Gout.,4.  Arthritis (DJD/rheumatoid).,5.  Diabetes mellitus.,6.  Hypothyroidism.,7.  Hypertension.,8.  GERD.,9.  Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married.  She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart.  It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:,  Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented.  Tinnitus in the right ear.  Diabetes and hypothyroidism.  Chronic nausea.  Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back.  Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking.  She says her mood is sad and may be depressed and she is also extremely anxious.  She has chronic shortness of breath and coughs easily when has to breathe deeply.  She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66.  Respiratory rate is 20.  Weight is 257 pounds.  Pain scale is 7.,GENERAL:  This is a somewhat anxious elderly African-American female who tends to amplify findings on examination.  It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw.  She is obese.,HEENT:  She is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  Tympanic membranes were visualized bilaterally.  There is tenderness to palpation of any sinus region.  There are no palpable cervical nodes.,NECK:  Supple although she complains of pain when rotating her neck.,CHEST:  Clear to auscultation bilaterally.,HEART:  Heart sounds are distant.  There are no carotid bruits.,EXTREMITIES:  She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  She is alert and oriented x3.  Her speech is fluent; however, she is extremely tangential.  She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES:  Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR:  This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity.  There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout.  Her tone is normal throughout.,SENSORY:  She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg.  She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION:  There is no obvious dysmetria.,GAIT:  She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker.  There are some mild right lower extremity circumduction present.,REFLEXES:  Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent.  Toes are equivocal.,OTHER:  Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, ""Oh my back, oh my back"", and was unable to complete the maneuver.  Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:,  This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology.  Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings.  I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise.  I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency.  In addition, we will attempt to get further objective data by ENG testing.  I will see the patient again after these tests are completed and she has a trial of the Antivert.",Dizziness - Recurrent,Neurology,
"Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.","HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.",Lumbosacral Polyradiculopathy,Neurology,
"The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes.   She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.","DELIVERY NOTE:,  The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.  She was Group B Streptococcus positive, however, was 5 cm dilated.  The patient was started on Group B Streptococcus prophylaxis with ampicillin.  She received a total of three doses throughout her labor.  Her pregnancy was complicated by scanty prenatal care.  She would frequently miss visits.  At 37 weeks, she claims that she had a suspicious bump on her left labia.  There was apparently no fluid or blistering of the lesion.  Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2.  I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  The patient requested an epidural anesthetic, which she received with very good relief.  She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  The baby delivered in the occiput anterior position.  The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  The umbilical cord was doubly clamped and then cut.  The baby's Apgars were 8 and 9.  The placenta was delivered spontaneously intact.  There was a three-vessel cord with normal insertion.  The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol.  The perineum was inspected and was found to be fully intact.  Estimated blood loss was approximately 400 mL.  The patient's blood type is A+.  She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.",Delivery Note - 7,Obstetrics / Gynecology,"obstetrics / gynecology, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: 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.,"
Arthroscopic procedure of the knee.,"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 in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis.  Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  Through the lateral portal, the camera was placed.  Through the medial portal, tools were placed.  We proceeded to examine scarring of the patellofemoral joint.  Then we probed the patellofemoral joint.  A chondroplasty was performed using a shaver.  Then we moved down to the lateral gutter.  Some loose bodies were found using a shaver and dissection.  We moved down the medial gutter.  No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact.  We moved to the lateral joint and found that the lateral meniscus was intact.  Pictures were taken.  We drained the knee and washed out the knee with copious amounts of sterile saline solution.  The instruments were removed.  The 2 portals were closed using 3-0 nylon suture.  Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed.  The patient was successfully extubated and brought to the recovery room in stable condition.  I then spoke with the family going over the case, postoperative instructions, and followup care.",Knee Arthroscopy - 1,Orthopedic,"orthopedic, chondroplasty, knee, meniscus, patellofemoral, arthroscopy, portals, jointNOTE,: 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 a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.","HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.  The patient stated initial injury occurred eight years ago, when she fell at a ABC Store.  The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection.  The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall.  The patient gave birth in August 2008 and since the childbirth, has experienced low back pain.  The patient also states that she fell four to five days ago, while mopping her floor.  The patient stated that she landed on her tailbone and symptoms have increased since that fall.  The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions.  The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant.  The patient has had a C-section and also an appendectomy.  The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1.  Vicodin 500 mg two times a day.,2.  Risperdal.,3.  Zoloft.,4.  Stool softeners.,5.  Prenatal pills.,DIAGNOSTIC IMAGERY:  ,The patient states she has not had an MRI performed on her lumbar spine.  The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time.  Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE:  ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather.  The patient states that pain is dramatically less, when the weather is warmer.  The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning.  The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back.  Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE:  26 years old.  HEIGHT:  5 feet 2 inches.  WEIGHT:  The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION:  ,The patient complained of bilateral SI joint point tenderness.  The patient also complained of left greater trochanter hip point tenderness.  The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH:  ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5.  With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance.  It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL:  ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes.  However, they subside when she stands.  The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes.  Upon standing, the patient stated that the numbness and tingling subsides almost immediately.  The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities.  The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT:  ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT:  ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain.  The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued.  At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1.  The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2.  The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3.  The patient will report 25% improvement in her functional and ADL activities.,4.  Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1.  The patient will be independent with home exercise program.,2.  Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3.  The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4.  The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5.  The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1.  Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.",Physical Therapy - Low Back Pain,Orthopedic,
"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 - 5,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal"
"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,"
"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,Neurosurgery,"neurosurgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,"
Exploratory laparotomy and right salpingectomy.,"PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with 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 grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  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.",Laparotomy & Salpingectomy,Obstetrics / Gynecology,"obstetrics / gynecology, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles,"
"MRI Brain, Carbon Monoxide poisoning.","CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual ""anxiety"" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.",MRI Brain - CO poisoning,Radiology,
"Endoscopic release of left transverse carpal ligament.  Steroid injection, stenosing tenosynovitis of right middle finger.","PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1.  Endoscopic release of left transverse carpal ligament.,2.  Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA:  ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 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 mL 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.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL.  A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",Carpal Ligament Release - 2,Orthopedic,"orthopedic, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger"
"Macular edema, right eye.  Insertion of radioactive plaque, right eye with lateral canthotomy.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.","PREOPERATIVE DIAGNOSIS:,  Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual manner for a local eye procedure.  Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done.  Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus.  A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.  Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut.  The intraocular pressure was found to be within normal limits.  An eye patch was applied and the patient was sent to the Recovery Room in good condition.  A lateral canthotomy had been done.",Radioactive Plaque - Insertion,Ophthalmology,"ophthalmology, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular"
"A 21-month-old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye.""","CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left ""intoeing."" His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for ""quivering"" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with ""lazy eye."" No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.",Lobar Holoprosencephaly,Neurology,"neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine,"
Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.  A 2 cm infraumbilical midline incision was made.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.,"PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,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 axillary line approximately 3 cm above the anterior superior 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 close to the gallbladder.  The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips.  Several attempts at passing the cholangiocatheter into the ductotomy were made.  Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct.  After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography.  The distal cystic duct was doubly clipped.  The duct was divided between the clips.  The clips were carefully placed to avoid occluding the juncture with the common bile duct.  The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly 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 port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery.  Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,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 then secured with a Kocher clamp, and 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 & Cholangiogram - 1,Gastroenterology,"gastroenterology, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula,"
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,"
"Bilateral rectus recession with the microscopic control, 8 mm, both eyes.","PREOPERATIVE DIAGNOSIS:,  Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:,  Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position.  The general anesthesia was achieved with intubation with no problems.  Both eyes were prepped and draped in usual manner.  The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape.  The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem.  The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position.  Inferior fornix conjunctival incision was made and Tenons capsule buttonholed.  The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook.  The Tenons capsule was buttonholed.  The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle.  __________ extension of the muscle was excised.  The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders.  The muscle was disinserted from original insertion.  The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion.  The suture was pulled, tied, and cut.  The muscle was in good position.  The conjunctiva was closed with 7-0 Vicryl suture in running fashion.  The suture was pulled, tied, and cut.  The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion.  The suture was pulled, tied and cut.  The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut.  TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition.  To be seen in the office in 1 week.",Rectus Recession,Ophthalmology,"ophthalmology, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus,"
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,Orthopedic,"orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast"
Bronchoscopy.  Atelectasis and mucous plugging.,"PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV.  Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  The main carina was visualized.  The trachea was free of any secretions.  The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  Left mainstem appeared patent.  Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  The area was lavaged with some saline and cleared.  The patient tolerated the procedure well.",Bronchoscopy,Cardiovascular / Pulmonary,"cardiovascular / pulmonary,"
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,Psychiatry / Psychology,
Exam under anesthesia.  Removal of intrauterine clots.  Postpartum hemorrhage,"PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:,  Exam under anesthesia.  Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:,  Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery.  I was called for persistent bleeding and passing large clots.  I examined the patient and found her to have at least 500 mL of clots in her uterus.  She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her.  I did advise her that I would recommend they came under anesthesia and dilation and curettage.  Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed.  She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion.  Bimanual exam revealed moderate amount of clot in the uterus.  I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed.  I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found.  At this point, the procedure was terminated.  Bleeding at this time was minimal.  Preop H&H were 8.3 and 24.2.  The patient tolerated the procedure well and was taken to the recovery room in good condition.",Intrauterine Clots Removal,Obstetrics / Gynecology,"obstetrics / gynecology, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,"
"Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.","MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.",Mayoview - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,"
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,
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,
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 - 2,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"
"Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  Hypertension, which is finally better controlled.  Metabolic bone disease and anemia.","HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease.  His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him.  I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  He has also brought a machine at home, and states his blood pressure readings have been better.  He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.  He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative.  He continues to feel well.  He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1.  Vytorin 10/40 mg one a day.,2.  Rocaltrol 0.25 micrograms a day.,3.  Carvedilol 12.5 mg twice a day.,4.  Cozaar 50 mg twice a day.,5.  Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  GENERAL:  He is a thin African American gentleman in no distress.  LUNGS:  Clear.  CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1 and S2.  I did not appreciate a murmur.  ABDOMEN:  Soft.  He has a very soft systolic murmur at the left lower sternal border.  No rubs or gallops.  EXTREMITIES:  No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9.  He is not on EPO yet.  His UA has been negative.,IMPRESSION:,1.  Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  His estimated GFR is 16 mL per minute.  He has no uremic symptoms.,2.  Hypertension, which is finally better controlled.,3.  Metabolic bone disease.,4.  Anemia.,RECOMMENDATION:,  He needs a number of things done in terms of followup and education.  I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  I also gave him websites that he can get on to find out more information.  I have not made any changes in his medications.  He is getting blood work done prior to his next visit with me.  I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05.  He will see me back in about 4 to 6 weeks.",Chronic Kidney Disease Followup,Nephrology,"nephrology, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney"
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.,Neurology,
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,Gastroenterology,"gastroenterology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct"
"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,"
Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.,"PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.",Vaginal Delivery - Vacuum-Assisted,Obstetrics / Gynecology,"obstetrics / gynecology, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions,"
"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 - 3,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,"
Dysarthria.  Probable brainstem glioma.,"CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally ""giddy."" Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.",Glioma - 1,Neurology,
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,
"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,
"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,
"Total left knee replacement.  Degenerative arthritis of the left knee.  Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.","PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03.  The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA:  ,General.,IMPLANT USED FOR PROCEDURE:,  NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component.  The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY:  ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living.  He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc.  This has only provided him with temporary relief.  It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain.  He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table.  At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure.  The tourniquet was then inflated to 325 mmHg.  At this time, a standard midline incision was made towards the total knee.  We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus.  We did start off with a small midline skin incision in case we were going to do a unicompartmental.  Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement.  It is for this reason that we extended the incision and underwent with the total knee replacement.  Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella.  Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide.  A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee.  At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur.  At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation.  Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues.  Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus.  This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed.  At this time, the intramedullary guide was removed and a final cutting block was placed.  This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking.  At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues.  An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut.  Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces.  At this time with a better exposure of the proximal tibia, we placed external tibial guide.  This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia.  At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy.  Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection.  At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments.  Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface.  The knee was taken through range of motion and revealed excellent femorotibial articulation.  The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release.  Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis.  At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut.  At this time, the prosthesis was removed.  A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia.  Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components.  At this time, polymethyl methacrylate cement was then mixed.  The cement was placed on the tibial surface as well as the underneath surface of the component.  The component was then placed and impacted with excess cement removed.  In a similar fashion, the femoral component was also placed.  A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content.  Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone.  Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry.  The knee was again taken through range of motion with a 12 mm plastic as well as #14.  The #14 appeared to be a bit too tight especially in extremes of flexion.  We decided to go with a #12 mm polyethylene tray.  At this time, this was placed to the tibial articulation and then left in place.  This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia.  The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact.  A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried.  #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion.  A tight capsular closure was performed.  This was reinforced with a #1-0 running Vicryl suture.  At this time, the knee was again taken through range of motion to assure tight capsular closure.  At this time, copious irrigation was used to irrigate the superficial wound.  #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture.  The skin was then approximated with staples.  The leg was then cleansed.  Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied.  At this time, the patient was extubated and transferred to recovery in stable condition.  Prognosis is good for this patient.",Total Knee Replacement,Orthopedic,"orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation,"
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,Hematology - Oncology,"hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma"
"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,
"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,
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"
"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,Neurology,"neurology, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,"
A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.,"Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.",Wilson's Disease - Letter,Neurology,"neurology, atrial enlargement, wilson's disease, penicillamine,"
"First Pap smear, complaining of irregular periods.  - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.","CHIEF COMPLAINT:,  The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:,  The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods.  She notes that her periods are out of weck.  She says that she has cramping and pain before her period starts.  Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks.  She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed.  The cramping is worse.  She said her flow has increased.  She has to change her pad every half to one hour and uses a super tampon sometimes.  She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad.  She also notes that her headaches have been worsening a little bit.  She has had quite a bit of stress.  She had a headache on Wednesday again after having had one on the weekend.  She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them.  She avoids caffeine.  She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is a nonsmoker.  She is not sexually active.,PAST MEDICAL HISTORY:,  She has had no surgery or chronic illnesses.,FAMILY HISTORY:,  Mother has hypertension, depression.  Father has had renal cysts and sometimes some stomach problems.  Both of her parents have problems with their knees.,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.,HEENT:  See HPI.,Neck:  No stiffness, pain or swelling.,Respiratory:  No shortness of breath, cough or hemoptysis.  She is a nonsmoker.,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:,VITALS:  Height 64.5 inches.  Weight:  162 pounds.  Blood pressure 104/72.  Pulse:  72.  Respirations:  16.  LMP:  08/21/04.  Age:  19.,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.,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 pink, scanty discharge.  Cervix without lesion.  Pap was taken.  Uterus normal size.  Adnexa:  No masses.  She does have some pain on palpation of the uterus.,Rectal:  Good sphincter tone.  No masses.  Stool is guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.,Rectal:  No mass.,ASSESSMENT:,  Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:,  We will evaluate with a CBC, urinalysis and culture, and TSH.  The patient has what she describes as migraine headaches of a new onset.  Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram.  We will evaluate with a CT scan of the brain with and without contrast.  We will try Anaprox DS one every 12 hours for the headache.  At this point, she could also use that for menstrual cramping.  Prescription written for 20 tablets.  If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow.  The lab x-ray and urinalysis results will be reported to her as soon as they are available.",First Pap smear.,Obstetrics / Gynecology,
"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,"
"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,
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"
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 - 12,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,"
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,Nephrology,
"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 - 7,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,"
"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,
Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,"PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,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.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.",Aortobifemoral Bypass - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,"
Discharge summary of a patient with depression and high risk behavior.,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.",Psychiatric Discharge Summary - 2,Psychiatry / Psychology,
"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,
The patient with a recent change in bowel function and hematochezia.,"PREPROCEDURE DIAGNOSIS:,  Change in bowel function.,POSTPROCEDURE DIAGNOSIS:,  Proctosigmoiditis.,PROCEDURE PERFORMED:,  Colonoscopy with biopsy.,ANESTHESIA: , IV sedation.,POSTPROCEDURE CONDITION: , Stable.  ,INDICATIONS:,  The patient is a 33-year-old with a recent change in bowel function and hematochezia.  He is here for colonoscopy.  He understands the risks and wishes to proceed.  ,PROCEDURE: , The patient was brought to the endoscopy suite where he was placed in left lateral Sims position, underwent IV sedation.  Digital rectal examination was performed, which showed no masses, and a boggy prostate.  The colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  In the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,RECOMMENDATIONS: , Follow up with me in 2 weeks and we will begin Canasa suppositories.",Colonoscopy with Biopsy - 1,Gastroenterology,"gastroenterology, change in bowel function, iv sedation, bowel function, proctosigmoiditis, sedation, rectum, bowel, function, colonoscopy, hematochezia,"
Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.,"DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.",Disseminated Intravascular Coagulation,Hematology - Oncology,"hematology - oncology, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,"
"Excision basal cell carcinoma, right medial canthus with frozen section, and reconstruction of defect with glabellar rotation flap.","PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:,  Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus.  She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table.  The face was prepped with pHisoHex draped.  The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology.  The report was ""basal cell carcinoma with all margins free of tumor.""  Hemostasis was controlled with the Bovie.  Excised lesion diameter was 1.2 cm.  The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin.  The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin.  Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment.  The patient was returned to the recovery room in satisfactory condition.  She tolerated the procedure satisfactorily, and then no complications.  Blood loss was essentially nil.",BCCa Excision - Canthus,Hematology - Oncology,"hematology - oncology, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,"
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,
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,
"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,
"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,"
"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,Psychiatry / Psychology,
"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,
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 - 3,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,"
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,
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) - 1,Cardiovascular / Pulmonary,
Lexiscan Nuclear Myocardial Perfusion Scan.  Chest pain.  Patient unable to walk on a treadmill.  Nondiagnostic Lexiscan.  Normal nuclear myocardial perfusion scan.,"EXAM:,  Lexiscan Nuclear Myocardial Perfusion Scan.,INDICATION:,  Chest pain.,TYPE OF TEST:  ,Lexiscan, unable to walk on a treadmill.,INTERPRETATION: , Resting heart rate of 96, blood pressure of 141/76.  EKG, normal sinus rhythm, nonspecific ST-T changes, left bundle branch block.  Post Lexiscan 0.4 mg injected intravenously by standard protocol.  Peak heart rate was 105, blood pressure of 135/72.  EKG remains the same.  No symptoms are noted.,SUMMARY:,1.  Nondiagnostic Lexiscan.,2.  Nuclear interpretation as below.,NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:,  Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol.  Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake.  There is no evidence of reversible or fixed defect.  Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery.  Ejection fraction calculated at 41%.  End-diastolic volume of 115, end-systolic volume of 68.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 41% by gated SPECT.",Lexiscan Nuclear Scan,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, lexiscan nuclear myocardial perfusion scan, treadmill, bundle branch block, mci, tetrofosmin, nuclear myocardial perfusion scan, blood pressure, gated spect, ejection fraction, myocardial perfusion, ejection, fraction, myocardial, lexiscan, nuclear,"
Right Achilles tendon rupture.,"CHIEF COMPLAINT:,  Achilles ruptured tendon.,HISTORY:,  Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola.  He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg.  He was seen locally and diagnosed with an Achilles tendon rupture.  He has been on crutches and has been nonweightbearing since that time.  He had no pain prior to his injury.  He has had some swelling that is mild.  He has just been on aspirin a day due to his traveling time.  Pain currently is minimal.,PAST MEDICAL HISTORY:,  Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:,  Malarone, which is an anti-malarial.,ALLERGIES:,  NKDA,SOCIAL HISTORY:,  He is a petroleum engineer for Chevron.  Drinks socially.  Does not use tobacco.,PHYSICAL EXAM:,  Pleasant gentleman in no acute distress.  He has some mild swelling on the right ankle and hindfoot.  He has motion that is increased into dorsiflexion.  He has good plantarflexion.  Good subtalar, Chopart and forefoot motion.  His motor function is intact although weak into plantarflexion.  Sensation is intact.  Pulses are strong.  In the prone position, he has diminished tension on the affected side.  There is some bruising around the posterior heel.  He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him.  Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:,  Of his right ankle today show a preserved joint space.  I don't see any evidence of fracture noted.  Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:,  Right Achilles tendon rupture.,PLAN:,  I have gone over with Mr. XYZ the options available.  We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment.  Based on his age and his activity level, I think his best option is for operative fixation.  We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery.  We have discussed doing this as an outpatient procedure.  He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼"" lift.  He understands a 6-9 month return to sports overall.  He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola.  Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1"" lift also.  He can weight bear until surgery and we will have it set up this week.  His questions were all answered today.",Achilles Ruptured Tendon,Orthopedic,"orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles,"
"Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.","ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.",Pyelonephritis - Discharge Summary,Nephrology,"nephrology, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit"
"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,
"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,"
Difficulty with both distance vision and with fine print at near.,"REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient.  He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:,  Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving.  He is also having trouble when he is reading.  He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old.  However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents.  He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history.  He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:,  Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye.  Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16.  Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye.  The add was +2 in both eyes.  Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits.  Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted.  On examination of the macula, there were drusen scattered temporally.  Examination of the vasculature was normal.  Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6.  Of note, there were no disc hemorrhages.  On examination of the macula, there was scattered tiny drusen centrally and superiorly.  Examination of the vasculature was entirely normal.  Peripheral fundus examination was unremarkable.,ASSESSMENT:,1.  Age-related macular degeneration category three (right greater than sign left).,2.  Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3.  Presbyopia and astigmatism.,4.  Non-visually significant cataracts bilaterally.,PLANS:,1.  The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2.  Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3.  Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4.  Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5.  Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6.  We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.",Difficulty Distance Vision & Fine Print at Near,Ophthalmology,
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,
Concomitant chemoradiotherapy for curative intent patients.,"CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.",Concomitant Chemoradiotherapy,Hematology - Oncology,"hematology - oncology, tumor cells, concomitant chemoradiotherapy, chemotherapy, 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."
Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,"PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.",Tonsillectomy & Adenoidectomy - 2,ENT - Otolaryngology,"ent - otolaryngology, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy"
Endoscopic proximal shunt revision.,"PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.",Shunt Revision - 1,Neurosurgery,"neurosurgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,"
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,Orthopedic,"orthopedic, 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, postsurgical, spine, annular, bulging,"
Fractional dilatation and curettage,"PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.",Dilatation & Curettage - D&C,Obstetrics / Gynecology,"obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage"
"Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.","PREOPERATIVE DIAGNOSES:,1.  Nasopharyngeal mass.,2.  Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1.  Nasopharyngeal tube mass.,2.  Right upper lid skin lesion.,PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Excision of nasopharyngeal mass via endoscopic technique.,3.  Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan.  The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  It appears to be growing in size and is irregularly bordered.  After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position.  After this, the patient was turned to 90 degrees by the Department of Anesthesia.  The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade.  After this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors.  After this, the ________ was then hemostatically controlled with monopolar cauterization.  The patient's skin was then reapproximated with a running #6-0 Prolene suture.  A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment.  Attention then was drawn to the nasopharynx.  The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  The patient had a severely deviated nasal septum more so to the right than the left.  There appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  After this, the lesion was then removed on the right side with the XPS blade.  The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  This area was taken down with the XPS blade.  Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter.  After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  After this, the patient was then hemostatically controlled with suctioned Bovie cauterization.  A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment.  The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia.  The patient was extubated in the operating room and was transferred to the recovery room in stable condition.  The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.",Sinus Surgery - Endoscopic,ENT - Otolaryngology,"ent - otolaryngology, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,"
"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,Orthopedic,"orthopedic, 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"
"Melena and solitary erosion over a fold at the GE junction, gastric side.","PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.",Endoscopy - 2,Gastroenterology,"gastroenterology, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,"
"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,Neurology,"neurology, 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,"
"MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.","CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.",MRI Brain - Cryptococcus,Neurology,"neurology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf,"
Patient is here to discuss possible open lung biopsy.,"CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.",Lung Biopsy Discussion,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, 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.,"
"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 - 1,Obstetrics / Gynecology,
Admission Psychiatric Evaluation,"ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA:  ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister.  She also has a stepsister that is 8 years old.  The patient was brought in by her mother after being picked up by Anchorage Police Department (APD).  She was brought to our institution for an assessment.  ,REASON FOR ADMISSION/CHIEF COMPLAINT:  ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then.  Her friends report to the parents that she is suicidal and that she had a knife.  A friend took a knife away from her to keep her from cutting herself.  ,HISTORY OF PRESENT ILLNESS:  ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents.  This is her first admission.  APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal.  The mother found journals in her room talking about suicide, and that she has been raped.  There were no details and the client denies that she was raped.  She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year.  She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage.  She reports symptoms of depression, no energy, initial and middle insomnia, eating more.  She is very irritable and has verbal altercations wither sister who is 14.  She admits to being sad and also having poor concentration.  She had marked drop in school functioning in the last year, and will need to repeat the ninth grade.  The mother is very concerned with the patent's safety and feels she is not able to control her.  She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican.  She went to live with her dad up to age 16.  Now she is living with her mother and her mother's boyfriend for the last two months.  In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY:  ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY:  ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family.  ,FAMILY PSYCHIATRIC HISTORY:  ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY:  ,She was born with some eczema.  At age 4 she was involved in an accident where she cut one of her legs and needed sutures.  There is no history of seizure or head injury.  She reports loss of consciousness.  This will be investigated; there are no details about it.  She admits to being sexually active, protecting herself using condoms.  Her last menstruation period was 07/20/04.  ,ALLERGIES:  ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema.  Early milestones walk and talk.  The patient appears to function at the expected age level.  ,PERTINENT PSYCHOSOCIAL DATA:  ,Complete pertinent psychosocial will be obtained by our clinician.  The patient admits witnessing seeing some domestic violence when she was small, around five years old.  There is an allegation of a rape that the mother found in her journal, but this is going to be investigated.  ,SCHOOL HISTORY:",Psychiatric Evaluation - 4,Psychiatry / Psychology,
"Head injury, anxiety, and hypertensive emergency.","CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.",Head Injury,Pediatrics - Neonatal,
"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,Cardiovascular / Pulmonary,
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,Radiology,
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 - 2,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."
"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,Cardiovascular / Pulmonary,
"Lower extremity angiogram, superficial femoral artery laser atherectomy and percutaneous transluminal balloon angioplasty, external iliac artery angioplasty and stent placement, and completion angiogram.","PREOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Left superficial femoral artery subtotal stenosis.,2.  Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1.  Left lower extremity angiogram.,2.  Left superficial femoral artery laser atherectomy.,3.  Left superficial femoral artery percutaneous transluminal balloon angioplasty.  ,4.  Left external iliac artery angioplasty.,5.  Left external iliac artery stent placement.,6.  Completion angiogram.,FINDINGS:  ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh.  He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary.  However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery.  The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament.  Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area.  Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result.  The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity.  We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh.  After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed.  We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery.  We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire.  A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery.  Because of the findings as noted above, this became more involved than initially hoped for.  Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area.  Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery.  Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout.  He had good palpable dorsalis pedis pulses bilaterally on completion.  He was taken to the recovery room in satisfactory condition.  Protamine was given to partially reverse the heparin.",Angiogram & Angioplasty,Cardiovascular / Pulmonary,
"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 - 9,Cardiovascular / Pulmonary,
Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.,"PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.",Colonoscopy - 12,Gastroenterology,"gastroenterology, ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid, rectum, terminal ileum, olympus video colonoscope, flexure, 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.,"
"Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.7.  Microscopic dissection.","PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.",Anterior Cervical Discectomy & Arthrodesis,Neurosurgery,"neurosurgery, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,"
"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,
Discharge summary of a patient with depression and high risk behavior.,"DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,  This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.",Psychiatric Discharge Summary - 3,Psychiatry / Psychology,
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,Orthopedic,
"Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.","PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.",Pacemaker Lead Placement & Rrevision.,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular"
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,
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,"
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,
Open reduction and internal fixation of left tibia.,"PREOPERATIVE DIAGNOSIS: , Left tibial tubercle avulsion fracture.,POSTOPERATIVE DIAGNOSIS:,  Comminuted left tibial tubercle avulsion fracture with intraarticular extension.,PROCEDURE:,  Open reduction and internal fixation of left tibia.,ANESTHESIA: , General.  The patient received 10 ml of 0.5% Marcaine local anesthetic.,TOURNIQUET TIME: , 80 minutes.,ESTIMATED BLOOD LOSS:,  Minimal.,DRAINS: , One JP drain was placed.,COMPLICATIONS: , No intraoperative complications or specimens.  Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,HISTORY AND PHYSICAL:,  The patient is a 14-year-old male who reported having knee pain for 1 month.  Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee.  The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care.  Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta.  Surgery is recommended to the grandmother and subsequently to the father by phone.  Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal.  Risks of surgery include the risks of  anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab.  All questions were answered, and father and grandmother agreed to the above plan.,PROCEDURE: , The patient was taken to the operating and placed supine on the operating table.  General anesthesia was then administered.  The patient was given Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The patient's extremity was then prepped and draped in the standard surgical fashion.  Midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in Esmarch.  Finally, the patient had tourniquet that turned in 75 mmHg.  Esmarch was then removed.  The incision was then made.  The patient had significant  tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement.  We were able to see the underside of the anterior horn of both medial and lateral meniscus.  The intraarticular cartilage was restored using two 45 K-wires.  Final position was checked via fluoroscopy and the corners were buried in the cartilage.  There was a large free floating metaphyseal piece that included parts of proximal tibial physis.  This was placed back in an anatomic location and fixed using a 45 cortical screw with a washer.  The avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer.  The cortical screw did not provide good compression and fixation at this distal fragment.  Retinaculum was repaired using 0 Vicryl suture as best as possible.  The hematoma was evacuated at the beginning of the case as well as the end.  The knee was copiously irrigated with normal saline.  The subcutaneous tissue was re-approximated using 2-0 Vicryl and the skin with 4-0 Monocryl.  The wound was cleaned, dried, and dressed with Steri-Strips, Xeroform, and 4 x4s.  Tourniquet was released at 80 minutes.  JP drain was placed on the medium gutter.  The extremity was then wrapped in Ace wrap from the proximal thigh down to the toes.  The patient was then placed in a knee mobilizer.  The patient tolerated the procedure well.  Subsequently extubated and taken to the recovery in stable condition.,POSTOP PLAN:  ,The patient hospitalized overnight to decrease swelling and as well as manage his pain.  He may weightbear as tolerated using knee mobilizer.  Postoperative findings relayed to the grandmother.  The patient will need subsequent hardware removal.  The patient also was given local anesthetic at the end of the case.",ORIF - Left Tibia,Orthopedic,"orthopedic, intraarticular extension, tibial tubercle avulsion fracture, tubercle avulsion fracture, jp drain, cortical screw, hardware removal, tibial tubercle, tourniquet, orif, tubercle, tibial,"
"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,
Sample of Pulmonary Function Test,"SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted.  FEF25-75% is also within normal limits at 110% predicted.  FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%.  MVV is within normal limits.,LUNG VOLUMES:,  Shows total lung capacity to be normal.  RV as well as RV/TLC ratio they are within normal limits.,DIFFUSION CAPACITY:,  Shows that after correction for alveolar ventilation, is also normal.,Oxygen Saturation on Room Air:  98%.,FINAL INTERPRETATION:,  Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease.  There is some improvement after the use bronchodilator.  Diffusion capacity is within normal limits.  Oxygen saturation on room air is also normal.  Clinical correlation will be necessary in this case.",Pulmonary Function Test - 4,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity,"
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,Radiology,
"History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle.  Insertion of tissue expander to the medial and lateral wound.","PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1.  Wound debridement x2, including skin, subcutaneous, and muscle.,2.  Insertion of tissue expander to the medial wound.,3.  Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA:  ,General.,INDICATIONS: , This patient developed a compartment syndrome.  She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  She was doing very well and was obviously improving.,The swelling was reduced.  A compartment pressure had obviously improved based on examination.  She was therefore indicated for placement of tissue expander for ventral wound closure.  The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood them well.  All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:,  The patient was placed on the operating table and general anesthesia was achieved.  The medial wound was noted to be approximately 10.5 cm in length x 4 cm.  The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  Both wounds were then thoroughly debrided.  The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  At this point adequate debridement was performed and healthy tissue did appear to be present.  Initially on the medial wound I did place the DermaClose RC continuous external tissue expander.  On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  I then did place adequate tension on the sutures.  Continued tension will be noted after engaging the tension controller.  At this point I performed the similar procedure to the lateral wound.  The skin anchors were placed separately and appropriately on either side of the skin margin.  The line loop from the tension controller was placed in lace like manner through the skin anchors.  The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  Adequate tension was placed in this region.  A non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  No complications were encountered throughout the procedure and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.",Tissue Expander Insertion,Orthopedic,"orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment,"
"Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.","PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.",Arthroscopic Debridement & Labral Repair - Hip,Orthopedic,"orthopedic, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum"
Progressive loss of color vision OD.,"CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection.",Meningioma,Neurology,"neurology, goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma,"
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,Neurology,
"Radioactive plaque macular edema.  Removal of radioactive plaque, right eye with lateral canthotomy.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.","PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:,  Radioactive plaque macular edema.,TITLE OF OPERATION:,  Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure.  Then a retrobulbar injection of 2% Xylocaine was performed.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.  Next, the plaque was identified and the two scleral sutures were removed.  The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture.  The fundus was inspected with direct ophthalmoscopy.  An eye patch was applied following Neosporin solution irrigation.  The patient was sent to the recovery room in good condition.  A lateral canthotomy had been done.",Radioactive Plaque - Removal,Ophthalmology,"ophthalmology, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque"
"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,ENT - Otolaryngology,
"Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.","PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.",Craniotomy - Frontal Zygomatic,Neurosurgery,"neurosurgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies,"
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,Orthopedic,"orthopedic, 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,"
The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.,"DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.",Delivery Note - 10,Obstetrics / Gynecology,"obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: 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.,"
"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,Neurology,"neurology, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,"
"Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.","PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen 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 and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.",Low-Transverse C-Section - 2,Obstetrics / Gynecology,"obstetrics / gynecology, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine"
"Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.","PREOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:,  Left calcaneal valgus split.,PROCEDURES:  ,1.  Left calcaneal lengthening osteotomy with allograft.,2.  Partial plantar fasciotomy.,3.  Posterior subtalar and tibiotalar capsulotomy.,4.  Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS:  ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age.  Since that time, the patient has developed significant calcaneal valgus deformity with significant pain.  Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot.  Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening.  Risks and benefits of surgery were discussed with the mother.  Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months.  All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A bump was placed underneath the left buttock.  A nonsterile tourniquet was placed on the upper aspect of the left thigh.  The extremity was then prepped and draped in a standard surgical fashion.  The patient had a previous incision along the calcaneocuboid lateral part of the foot.  This was marked and extended proximally through the Achilles tendon.  Extremity was wrapped in Esmarch.  Tourniquet inflation was noted to be 250 mmHg.  Decision was then made to protect the sural nerve.  There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way.  Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh.  Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral.  Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally.  At this time, we also noted that calcaneocuboid joint appeared to be fused.  The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy.  This was performed with a saw.  After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi.  The osteotomy was completed with an osteotome and distracted with the lamina spreader.  A tricortical allograft was then shaped and subsequently impacted into this area.  Final positioning was checked with multiple views of fluoroscopy.  It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly.  A pin was subsequently bent and cut short at the level of the skin.  The wound was then irrigated with normal saline.  The Achilles was repaired with this tie.  Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening.  A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion.  Wound was then closed using #2-0 Vicryl and #4-0 Monocryl.  The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case.  The wound was clean and dry and dressed with Steri-Strips and Xeroform.  Skin was dressed with Xeroform and 4 x 4's.  Everything was wrapped with 4 x 4's in sterile Webril.  The tourniquet was released after 69 minutes.  A short-leg cast was then placed with good return of capillary refill to his toes.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control.  The patient to be strict nonweightbearing.  We will arrange for her to get a wheelchair.  The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control.  The patient will need an AFO script at that time.  Intraoperative findings are relayed to the parents.",Calcaneal Lengthening Osteotomy,Orthopedic,"orthopedic, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal,"
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,
Cholecystitis and cholelithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,"PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.",Laparoscopic Cholecystectomy - 7,Gastroenterology,"gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,"
Consultation for FCR tendinitis,"HISTORY OF PRESENT PROBLEM:,  XYZ was seen by Dr. ABC for an FCR tendinitis.  We do not have his reports, but by history she has had two cortisone shots.  She plays musical instruments, and it does bother her from time to time.  She was considering surgery, but she takes ibuprofen and it seems to be well-controlled.  She is here now for consultation. ,CLINICAL/PHYSICAL EXAMINATION: , ,General:  The patient is alert and oriented times three in no acute distress. ,Skin:  No skin breakdown or hyperhidrosis.,Vascular:  2+ radial and ulnar artery pulses.,Musculoskeletal:  Wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle, but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability.  The DRUJ is stable.  Flexion/extension of the fingers is all intact.  Forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.,Neurologic:  Negative Tinel's, Phalen's and compression median nerve test.  APB, EPL and first dorsal interosseous have 5/5 strength.  Forearm, elbow and shoulder exams reveal no neurologic compromise.,Gait:  Normal.,Neck:  Negative Spurling sign.  Negative signs of thoracic outlet.,HEENT:  Pupils equal and reactive with no asymmetry.,CLINICAL IMPRESSION:,  By history, possible FCR tendinitis.,EVALUATION/TREATMENT PLAN:  At this point, we have asked her some questions again.  She is not that sore at this point, and she has had a couple of cortisone shots.  Without being the initial treating physician, she has FCR tendinitis that fails to respond to cortisone shots.  She is a candidate for an FCR tunnel release.  It has been described and is effective for those patients with that problem.  My only consideration would be, if the patient should choose, to get an MRI when she is symptomatic to confirm the FCR tendinitis.  She will followup with Dr. ABC as needed or come back to us when she is thinking more along the lines of surgery.",FCR tendinitis,Orthopedic,"orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr"
Left carpal tunnel release.  Left carpal tunnel syndrome.  Severe compression of the median nerve on the left at the wrist.,"PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:,  Left carpal tunnel release.,FINDINGS:,  Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS:  ,None.,FLUIDS:,  500 mL of crystalloids.,URINE OUTPUT:,  No Foley catheter.,COMPLICATIONS: , None.,ANESTHESIA: , General through a laryngeal mask.,ESTIMATED BLOOD LOSS: , None.,CONDITION: , Resuscitated with stable vital signs.,INDICATION FOR THE OPERATION: , This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation.  At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  He understood this risk and agreed to have the procedure performed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress.  After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  The left upper extremity was then prepped with Betadine soap and antiseptic solution.  After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg.  Clamp time approximately 30 minutes.  An incision was then made right in the mid palm area between the thenar and hypothenar eminence.  Meticulous hemostasis of any bleeders were done.  The fat was identified.  The palmar aponeurosis was identified and cut and this was traced down to the wrist.  There was severe compression of the median nerve.  Additional removal of the aponeurosis was performed to allow for further decompression.  After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches.  Dressing was applied.  The patient was brought to the recovery.",Carpal Tunnel Release - 6,Orthopedic,"orthopedic, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal,"
"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,
CT maxillofacial for trauma.  CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,"EXAM:  ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims.  The ethmoid, sphenoid, and frontal sinuses are clear.  There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally.  There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.  The nasal bones appear intact.  The zygomatic arches are intact.  The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes.  The mandible and maxilla are intact.  There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1.  Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally.  There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2.  Mild soft tissue swelling about the right cheek.",CT Maxillofacial,ENT - Otolaryngology,"ent - otolaryngology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial"
"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,"
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,ENT - Otolaryngology,
"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,
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,"
Anterior cranial vault reconstruction with fronto-orbital bar advancement.,"INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.",Cranial Vault Reconstruction,Neurosurgery,"neurosurgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,"
Esophagogastroduodenoscopy.   The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.,"PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.",Esophagogastroduodenoscopy - 6,Gastroenterology,"gastroenterology, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: 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.,"
"Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.","PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.",Culdoplasty & Vaginal Hysterectomy,Obstetrics / Gynecology,"obstetrics / gynecology, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic,"
Open reduction and internal fixation of left distal radius.,"PREOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture, metaphyseal extraarticular.,PROCEDURE: , Open reduction and internal fixation of left distal radius.,IMPLANTS:  ,Wright Medical Micronail size 2.,ANESTHESIA: , LMA.,TOURNIQUET TIME: , 49 minutes.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PATHOLOGY: , None.,TIME OUT: , Time out was performed before the procedure started.,INDICATIONS:,  The patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis.  The patient was in early stage of gestation.  Benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,DESCRIPTION OF PROCEDURE: , Supine position, LMA anesthesia, well-padded arm, tourniquet, Hibiclens, alcohol prep, and sterile drape.,Exsanguination achieved, tourniquet inflated to 250 mmHg.  First, under fluoroscopy the fracture was reduced.  A 0.045 K-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction.  A 2-cm radial incision, superficial radial nerve was exposed and protected.  Dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius.  The guidewire was inserted under fluoroscopy.  A cannulated drill was used to drill antral hole.  Antral awl was inserted.  Then we reamed the canal to size 2.  Size 2 Micronail was inserted to the medullary canal.  Using distal locking guide, three locking screws were inserted distally.  The second dorsal incision was made.  The deep radial dorsal surface was exposed.  Using locking guide, two proximal shaft screws were inserted and locked the nail to the radius.  Fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius.  At this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers.  Sterile dressing applied.  The patient then was extubated and transferred to the recovery room under stable condition.,Postoperatively, the patient will see a therapist within five days.  We will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.",ORIF of Left Distal Radius,Orthopedic,"orthopedic, distal radius fracture, dorsal extensor, locking guide, radius fracture, extraarticular, metaphyseal, guidewire, fracture, dorsal, distal,"
Exercise myocardial perfusion study.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%,"CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.",Exercise Myocardial Perfusion Study,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia,"
"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:  37.1",Small Bowel Obstruction,Gastroenterology,
Bilateral carotid ultrasound.,"EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.",Carotid Ultrasound,Neurology,"neurology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity"
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,Neurology,
"Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies.  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.","POSTOPERATIVE DIAGNOSIS:,  Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:,  Flexible fiberoptic bronchoscopy diagnostic with:,a.  Right middle lobe bronchoalveolar lavage.,b.  Right upper lobe bronchoalveolar lavage.,c.  Right lower lobe transbronchial biopsies.,COMPLICATIONS:,  None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION:  ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:,  After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions.  The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure.  2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved.  Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx.  Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg.  With this, adequate consciousness sedation was achieved.  3 cc of 4% viscous Xylocaine was applied to the right nares.  The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions.  Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc.  The bronchoscope was then advanced through the larynx into the trachea.  The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions.  These were suctioned clear.  The bronchoscope was then advanced through the carina, which was sharp.  Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized.  There was mild tracheobronchitis with mild friability throughout.  There was modest amounts of white secretion.  There were no other findings including evidence of mass, anatomic distortions, or hemorrhage.  The bronchoscope was subsequently withdrawn and advanced into the right mainstem.  Again, each segment and subsegment was well visualized.  The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments.  No specific masses or other lesions were identified throughout the tracheobronchial tree on the right.  There was mild tracheal bronchitis with friability.  Upon coughing, there was punctate hemorrhage.  The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe.  These again had no other anatomic lesions identified.  The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained.  The bronchoscope was withdrawn and the area was suctioned clear.  The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed.  Samples were taken and the bronchoscope was removed suctioned the area clear.  The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe.  Minimal hemorrhage was identified and suctioned clear without difficulty.  The bronchoscope was then withdrawn to the mainstem.  The area was suctioned clear.  Fluoroscopy revealed no evidence of pneumothorax.  The bronchoscope was then withdrawn.  The patient tolerated the procedure well without evidence of desaturation or complications.",Flexible Fiberoptic Bronchoscopy -1,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,"
"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 - 2,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"
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,"
"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,
"Incision and drainage and excision of the olecranon bursa, left elbow.  Acute infected olecranon bursitis, left elbow.","PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.",Olecranon Bursa - Excision,Orthopedic,"orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa"
"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 - 2,Neurology,
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 - 7,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."
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,"
"Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.","HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.",Lumbosacral Polyradiculopathy,Neurology,
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 - 2,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,"
Fall/loss of consciousness.,"CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.",Epidural Fluid Collection,Neurology,"neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone,"
She progressed in labor throughout the day.  Finally getting the complete and began pushing.  Pushed for about an hour and a half when she was starting to crown.,"DELIVERY NOTE: , The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  Membranes ruptured this morning by me with some meconium.  An IUPC was placed.  Some Pitocin was started because the contractions were very weak.  She progressed in labor throughout the day.  Finally getting the complete at around 1530 hours and began pushing.  Pushed for about an hour and a half when she was starting to crown.  The Foley was already removed at some point during the pushing.  The epidural was turned down by the anesthesiologist because she was totally numb.  She pushed well and brought the head drown crowning, at which time I arrived and setting her up delivery with prepping and draping.  She pushed well delivering the head and DeLee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  With delivery of the head, I could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to RT in attendance.  Exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although I cannot see good fascia around the sphincter anteriorly.  The placenta separated with some bleeding seen and was assisted expressed and completely intact.  Uterus firmed up well with IV pit.  Repair of the tear with 2-0 Vicryl stitches and a 3-0 Vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  Once this was complete, mom and baby doing well.  Baby was a female infant.  Apgars 8 and 9.",Delivery Note - 4,Obstetrics / Gynecology,"obstetrics / gynecology, iupc, meconium, pitocin, epidural, rectum, sphincter, labor, perineum, pushed, 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.,"
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"
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,Neurology,"neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE"
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,
The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.,"PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.",Release of A1 Pulley,Orthopedic,"orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint"
"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,
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,
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,
Evaluation for chronic pain program,"REASON FOR EVALUATION:,",Knee & Back Pain,Orthopedic,
AP abdomen and ultrasound of kidney.,"EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.",Ultrasound - Kidney,Nephrology,"nephrology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral,"
Neurologic consultation was requested to evaluate her seizure medication and lethargy.,"REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,",Neurologic Consultation,Neurology,"neurology, lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal"
"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,"
Esophagogastroduodenoscopy and colonoscopy with polypectomy,"PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.",EGD - Colonoscopy - Polypectomy,Gastroenterology,
The patient is admitted with a diagnosis of acute on chronic renal insufficiency.,"HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.",Nephrology Consultation - 4,Nephrology,"nephrology, mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency,"
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,
"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"
OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis.,"PREOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,OPERATION PERFORMED:,  OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:,  Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy.  The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain.  Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow.  After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.",OssaTron Extracorporeal Shockwave Therapy,Orthopedic,"orthopedic, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave,"
LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.,"DIAGNOSIS:,1.  Broad-based endocervical poly.,2.  Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1.  LEEP procedure of endocervical polyp.,2.  Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop.  Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered.  The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in.  Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation.  The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding.  The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop.  Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures.  A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted.  The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.",LEEP,Obstetrics / Gynecology,"obstetrics / gynecology, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented"
Sample post dilation patient instructions.,"The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.",Post Dilation Instructions,Ophthalmology,"ophthalmology, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: 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."
Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.,"PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.",Juxtarenal Abdominal Aortic Aneurysm Repair,Gastroenterology,"gastroenterology, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery,"
Right argon laser assisted stapedectomy.  Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,"PREOPERATIVE DIAGNOSIS: , Bilateral progressive conductive hearing losses with probable otosclerosis.,POSTOPERATIVE DIAGNOSIS: , Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,OPERATION PERFORMED: , Right argon laser assisted stapedectomy.,DESCRIPTION OF OPERATION:  ,The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The patient's right ear was carefully prepped and then draped in the usual sterile fashion.  Slow infiltration of the external canal accomplished with 1% Xylocaine with epinephrine.  The earlobe was also infiltrated with the same solution.  A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon.  This could later be removed in bishop.  A reinspection of the ear canal was accomplished.  A 65 Beaver blade was used to make incision both at 12 o'clock and at 6 o'clock.  Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation.  Elevation was carried down to the fibrous annulus.  An annulus elevator was used to complete the elevation beneath the annular ligament.  The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain.  Palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified.  Palpation with a fine curved needle on the stapes itself revealed no movement.  A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani.  The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well.  The self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse.  The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured.  The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation.  A small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston.  The measuring device was used and a 4.25 mm slim shaft wire Teflon piston chosen.  It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate.  The hook was placed over the incus and measurement appeared to be appropriate.  A downbiting crimper was then used to complete the attachment of the prosthesis to the incus.  Prosthesis is once again checked for location and centering and appeared to be in ideal position.  Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph.  A small pledget of fat was also placed on the top of the incudo-prosthesis junction.  The mobility appeared excellent.  The flap was placed back in its normal anatomic position.  The external canal packed with small pledgets of Gelfoam and antibiotic ointment.  She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop.  Sutures will be out in a week and a recheck in Reno in four to five weeks from now.",Stapedectomy - Argon Lasor Assisted,ENT - Otolaryngology,"ent - otolaryngology, bilateral progressive conductive hearing loss, argon laser assisted, conductive hearing losses, intubation, argon, stapedectomy, otosclerosis, canal, earlobe, prosthesis, pledgets, laser"
"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"
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,"
"EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.","PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.",Video EEG - 3,Neurology,"neurology, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: 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,"
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,"
Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,"TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.",Intraocular Lens Implant,Ophthalmology,"ophthalmology, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye,"
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 - 1,Gastroenterology,
Carotid artery angiograms.,"PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,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 fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.",Bilateral Carotid Angiography,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,"
"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 - 2,Pediatrics - Neonatal,
Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.,"INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.",Intensity-Modulated Radiation Therapy,Hematology - Oncology,"hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: 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."
"Trigger finger release.  A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.","PROCEDURE: , Trigger finger release.,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 over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, 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 Finger Release,Orthopedic,"orthopedic, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision"
A 32-year-old male with shoulder pain.,"EXAM:,MRI RIGHT SHOULDER,CLINICAL:, A 32-year-old male with shoulder pain.,FINDINGS:,This is a second opinion interpretation of the examination performed on 02/16/06.,Normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,Normal humeral head without fracture or subluxation.,There is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. The remaining portions of the labrum are normal without osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). There is no diastasis of the acromioclavicular joint itself. There is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There are no effusions or masses.,IMPRESSION:,Changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,There is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. There is also mild narrowing of the subacromial space secondary to the os acromiale. This may be acting as an impinging lesion in the appropriate clinical setting.,There is no evidence of a rotator cuff tear.",MRI Shoulder - 3,Orthopedic,"orthopedic, impinging lesion, os acromiale, shoulder, tendon, acromiale, osseous"
Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.,"VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  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.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX 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 preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  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 XX mm posterior to the limbus in the supranasal and supratemporal quadrants.",Vitrectomy Opening,Ophthalmology,"ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: 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.,"
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 - 3,Orthopedic,
Hardware removal in the left elbow.,"PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.",Hardware Removal - Elbow,Orthopedic,"orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware,"
"Painful ingrown toenail, left big toe.  Removal of an ingrown part of the left big toenail with excision of the nail matrix.","PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.",Ingrown Toenail Removal,Orthopedic,"orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown,"
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,
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,Radiology,
"Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.","PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.",Neurology - Discharge Summary,Neurology,"neurology, interhemispheric, frontal lobe, head injury, brain, contusion"
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 - 7,Cardiovascular / Pulmonary,"cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,"
Sample cardiology office visit note.,"HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 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:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.",Cardiology Office Visit - 2,Cardiovascular / Pulmonary,
Sample cardiology office visit note.,"HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 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:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.",Cardiology Office Visit - 1,Cardiovascular / Pulmonary,
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,Orthopedic,"orthopedic, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord"
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 - 9,Cardiovascular / Pulmonary,
"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,
"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 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,Neurology,"neurology, 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,"
"Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.","PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was 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 medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.",Tenosynovectomy & Cortisone Injection,Orthopedic,"orthopedic, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,"
"Total hip replacement.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.","PROCEDURE:,  Total hip replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, the patient was turned on the side and secured in the hip table.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.  The gluteus maximus was incised and split proximally.  The piriformis and external rotators were identified.  These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  The hip was dislocated.  A femoral neck cut was made using the guidance of preoperative templating.  The femoral head was removed.  Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken.  The femur was retracted anteriorly and a complete labrectomy was performed.  Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  The trial shell was placed and found to have an excellent fit.  The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  Excellent purchase was obtained.  The trial liner was placed.,The femur was then flexed and internally rotated.  The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  An intramedullary hole was drilled into the femur to define the canal.  Reaming was performed until the appropriate size was reached.  The broaches were then used to prepare the femur with the appropriate amount of version.  Once the appropriate size broach was reached, it was used as a trial with head and neck placement.  Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  The hip was found to have excellent stability with the final chosen head-neck combination.  Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position.  The real head was impacted atop the stem.  If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  Excess cement was removed from the edges of the component.  Range of motion and stability were once again checked and found to be excellent.  Adequate hemostasis was obtained.  Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was closed with nylon.  Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.",Total Hip Replacement - 1,Orthopedic,"orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur"
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) - 5,Radiology,
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,
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,
"A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.","HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.",EMG/Nerve Conduction Study - 2,Neurology,"neurology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles,"