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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 | null |
Patient had some cold symptoms, was treated as bronchitis with antibiotics. | DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1. Hyperlipidemia.,2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. Remote history of carcinoma of the breast.,4. Remote history of right nephrectomy.,5. Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1. Metoprolol 25 mg p.o. b.i.d.,2. Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1. Prednisone 20 mg p.o. daily for seven days.,2. Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:, The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time. | Discharge Summary | Cardiovascular / Pulmonary | cardiovascular / pulmonary, acute respiratory failure, bronchitis, acute on chronic renal failure, severe hypertension, diastolic dysfunction, cold symptoms, iv steroids, nasal spray, nasal, steroids, |
Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection. | TITLE OF PROCEDURE: ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin. Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. The ascending aorta was crossclamped. Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia. The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened. End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture. The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture. A warm antegrade and retrograde cardioplegia were given. The aortic crossclamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventricular and atrial pacing wires were placed. The patient was fully warmed and weaned from cardiopulmonary bypass. The patient was decannulated in the routine fashion and Protamine was given. Good hemostasis was noted. A single mediastinal and left pleural chest tube were placed. The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch. The patient tolerated the procedure well. | CABG | Cardiovascular / Pulmonary | cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
Well-child check and school physical. | CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:, Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle.,REVIEW OF SYSTEMS:, He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising.,MEDICATIONS:, No daily medications.,ALLERGIES:, Cefzil.,IMMUNIZATIONS:, His immunizations are up to date.,PHYSICAL EXAMINATION:,General: He is alert and in no distress, afebrile.,HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear.,Neck: Supple.,Lungs: Clear to auscultation.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Tanner III.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. No rashes.,Hearing: Grossly normal.,ASSESSMENT:, Well child.,PLAN:, Anticipatory guidance for age. He is to return to the office in one year. | School Physical - 3 | Pediatrics - Neonatal | null |
Left retrosigmoid craniotomy and excision of acoustic neuroma. | PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL. | Craniotomy - Retrosigmoid | Neurology | neurology, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor |
Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet. | CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1. PENICILLIN.,2. KEFLEX.,3. BACTRIM.,4. SULFA.,5. ACE BANDAGES.,MEDICATIONS,1. Toprol.,2. Xanax.,3. Advair.,4. Ventolin.,5. Tylenol No. 3.,6. Advil.,REVIEW OF SYSTEMS:, Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age.,EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left.,ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee.,2. Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees. | Consult - Knee Pain | Orthopedic | orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, |
Noncontrast CT head due to seizure disorder. | EXAM:, CT head.,REASON FOR EXAM:, Seizure disorder.,TECHNIQUE:, Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift, intracranial mass, or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:, No acute process in the brain. | CT Head - 1 | Neurology | neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast, |
Orthopedic progress note for follow up of osteoarthritis, knees. | CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bilateral knees right worse than left.,Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. ,Duration: Months.,Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. ,Hip Pain: None. ,Back pain: None. ,Radicular type pain: None. ,Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:, No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living. ,REVIEW OF SYSTEMS:, No change.,Constitutional: Good appetite and energy. No fever. No general complaints.,HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion.,GI: | Osteoarthritis - Progress Note | Orthopedic | null |
Sample of Pulmonary Function Test | SPIROMETRY:, Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted. FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted. FRC is mildly decreased and RV is also mildly decreased. RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:, After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:, 98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease. There is no significant obstructive disease present. There is no improvement after the use of bronchodilator and diffusion capacity is normal. Oxygen saturation on room air is also adequate. Clinical correlation will be necessary in this case., | Pulmonary Function Test - 6 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary, |
Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. | PREOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition. | Neuroplasty | Orthopedic | orthopedic, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural, |
Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. | OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:, The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.,The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch. | Thromboendarterectomy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE |
Pain management for post-laminectomy low back syndrome and radiculopathy. | Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero. | Pain Management Consult - 1 | Orthopedic | orthopedic, pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome, |
Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot. | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus deformity, right foot.,2. Tailor bunion deformity, right foot.,PROCEDURES PERFORMED: ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:, Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:, A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw. A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position. At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis. Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg. Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made. The incision was carried deep utilizing both sharp and blunt dissections. All major neurovascular structures were avoided. At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified. This was then incised fully exposing the tendon and the abductor hallucis muscle. This was then resected from his osseous attachments and a small tenotomy was performed. At this time, a small lateral capsulotomy was also performed. Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision. The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field. A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye. The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position. The dorsal arm was made longer than the plantar arm to accommodate for fixation. At this time, the capital fragment was resected and shifted laterally into a more corrected position. At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation. Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site. Compression was noted to be excellent. All guide wires and 0.045-inch K-wires were then removed. Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field. The wound was then once again flushed with copious amounts of sterile normal saline. At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated. At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon. At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension. Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal. Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field. Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head. The head was then shifted medially into a more corrected position. A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site. This was noted to be in correct position and compression was noted to be excellent. Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field. The wound was once again flushed with copious amounts of sterile normal saline. The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon. At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site. The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion. The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot. The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot. After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A. The patient is to be nonweightbearing to the right foot. The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these. The patient tolerated the procedure and anesthesia well. Dr. A was present throughout the entire case. | Tailor Bunionectomy with Screw Fixation | Orthopedic | orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis, |
A two week well-child check. | SUBJECTIVE:, Patient presents with Mom for first visit to the office for two week well-child check. Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital. Nursing every two to three hours with normal voiding and stooling pattern. She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful. She is burping well, hiccuping, sneezing and burping appropriately. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing. Delivery at Newton Medical Center at 39 weeks, 5 days gestation. Birth weight was 3160 g. Length 49.5 cm. Head circumference 33 cm. Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1. Infant did well after delivery and was dismissed to home with Mom the following day. No other hospitalizations. No surgeries.,ALLERGIES: , None.,MEDICATIONS:, Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family. History of cancer and asthma on the paternal side of the family. Mom unsure of what type of cancer.,SOCIAL HISTORY:, Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas. Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn. There is no smoking in the home. Family does have one pet dog in home.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs: Weight 7 pounds, 1-1/5 ounces. Height 21 inches. Head circumference 35.8 cm. Temperature 97.7.,General: Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT: Atraumatic, normocephalic. Anterior fontanel soft and flat. Pupils equal, round and reactive. Sclerae clear. Red reflex present bilaterally. TMs clear bilaterally. Oropharynx: Mucous membranes moist and pink.,Neck: Supple, no lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No masses or organomegaly. Healing umbilicus.,GU: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis. Some increased pigment over the sacrum.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule. Gave two week well-child check handout to Mom. Plan follow up for the one month well-child check or as needed for acute care. Mom will call for feeding problems, breathing problems or fever. Otherwise, plan to see at one month. | Well-Child Check - 3 | Pediatrics - Neonatal | null |
Stroke in distribution of recurrent artery of Huebner (left) | CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an "odd fisted posture." She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness. | CT Brain - Stroke | Radiology | null |
Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation. | PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE: ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2. She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain. Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area. There was no evidence of infection on the imaging or with her laboratory studies. In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well. She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. She was placed on the operative table in the prone position. Back was prepared with Betadine, iodine, and alcohol. We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum. The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it. After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase. We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic. This was a combination of scar and overgrown bone. She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels. After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels. We used 10 x 32 mm spacers at both L4-L5 and L5-S1. This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3. This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level. Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well. The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin. Prior to closing the skin, we confirmed correct sponge and needle count. We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies. The Cell Saver blood was recycled and she was given two units of packed red blood cells as well. I was present for and performed the entire procedure myself or supervised. | Lumbar Re-exploration | Orthopedic | orthopedic, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware, |
Modified radical mastectomy. An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further. | PROCEDURE PERFORMED: , Modified radical mastectomy.,ANESTHESIA: , General endotracheal tube.,PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. Care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,An elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site. The skin incision was carried down to the subcutaneous fat but no further. Using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle. The lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi. Bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 Vicryl. The breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely. Once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,The axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein. The highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist. The axilla was then cleared of its contents by sharp dissection. Small vessels entering the axillary vein were clipped and divided. The axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein. The long thoracic nerve was cleared identified lying against the chest and was carefully preserved. The long thoracic nerve represented the posterior most aspect of the dissection. As the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved. The dissection continued caudally until the entire specimen was freed and delivered from the operative field. Copious water lavage was used to remove any debris, and hemostasis was obtained with Bovie electrocautery.,Two Jackson-Pratt drains were inserted through separate stab incisions below the initial incision and cut to fit. The most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major. These were secured to the skin using 2-0 silk, which was Roman-sandaled around the drain.,The skin incision was approximated with skin staples. A dressing was applied. The drains were placed on "grenade" suction. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition. | Radical Mastectomy - 1 | Obstetrics / Gynecology | obstetrics / gynecology, latissimus dorsi muscle, pectoralis major muscle, pectoralis fascia, axillary vein, thoracic nerve, radical mastectomy, pectoralis major, axillary, incision, mastectomy, fascia, muscle, pectoralis, |
Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access. | REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future. | Fundoplication & Gastrostomy Followup | Gastroenterology | gastroenterology, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication, |
Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction. | CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:, All other systems reviewed & are negative.,PAST MEDICAL HISTORY:, Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates | Acute Inferior Myocardial Infarction | Cardiovascular / Pulmonary | null |
Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement. | PROCEDURE:, Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male. He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease. Previous ST elevation MI.,REVIEW OF SYSTEMS., The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1. Visipaque 361 mL total dose.,2. Clopidogrel bisulphate (Plavix) 225 mg PO,3. Promethazine (Phenergan) 12.5 mg total dose.,4. Abciximab (Reopro) 10 mg IV bolus,5. Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6. Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1. Balloon catheter utilized: Manufacturer: Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2. Cordis Vista Brite Tip 6Fr JR 4.0,3. ACS/Guidant Sport .014" (190cm) Wire,4. Stent utilized: Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:, The overall left ventricular systolic function is mildly reduced. Left ventricular ejection fraction is 40% by left ventriculogram. Mild hypokinesis of the anterior wall of the left ventricle. There was no transaortic gradient. Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY: , There were no obstructing lesions in the left main coronary artery. Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery. A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. Post-procedure stenosis was 0%. There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:, The right coronary artery is dominant to the posterior circulation. There were no obstructing lesions in the right coronary artery. Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1. Severe two-vessel coronary artery disease.,2. Severe left anterior descending coronary artery disease. There was a 95% mid left anterior descending artery stenosis. The lesion was successfully stented.,3. Moderate left circumflex artery disease. There was a 50% left circumflex artery stenosis. Intervention not warranted.,4. The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1. Clopidogrel (Plavix) 75 mg PO daily for 1 year. | Cardiac Cath & Coronary Angiography | Cardiovascular / Pulmonary | null |
The patient is 14 months old, comes in with a chief complaint of difficulty breathing. | HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get worse and they drove here to Children's Hospital. He has a history of reactive airway disease. He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time. He has been on albuterol off and on over that period. He has had fever overnight. No vomiting, no diarrhea. Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department. Normal urine output. No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above. No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:, Up-to-date.,BIRTH HISTORY:, The child was full term, no complications, home with mom. No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home. No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL: The child is awake, alert, in moderate respiratory distress.,HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed. I felt the child was dehydrated on examination. We gave 20 mL/kg bolus of normal saline over one hour. The child was given Solu-Medrol 2 mg/kg IV. He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally. Normal heart size. No evidence of pneumothorax. No evidence of focal pneumonia. After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. The child's pulse ox on breathing treatments with 100% oxygen was 100%. Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time. After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia. The child has a normal level of alertness; however, has not had any vomiting here. I spoke with Dr. X, on call for hospitalist service. She has come down and evaluated the patient. We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family. The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES: ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT: ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION: ,Status asthmaticus, hypoxia.,PLAN: ,Admitted to Pediatrics. | Difficulty Breathing - ER Visit | Cardiovascular / Pulmonary | null |
Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization. Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion. | PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculography.,4. Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin. The pressure was held. The needle was removed over the guidewire. Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was flushed. Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire. The catheter was then guided into the left ventricle. The guidewire and dilator were then removed. The catheter was then flushed. LVEDP was measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material. LVEDP was then remeasured. Pullback was performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the left main coronary was unable to be engaged with this catheter. Thus it was removed over a guidewire. Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Left main coronary artery was then engaged. Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. The catheter was then removed from the ostium of the right coronary artery and then removed. The sheath was then flushed. Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization. Thus an #18 gauge Argon needle was used to cannulate the right femoral vein. A steel guidewire was inserted through the needle into the vascular lumen. The needle was removed over the guidewire. Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, a Swan-Ganz catheter was advanced to the level of 20 cm. The balloon was inflated. Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position. Hemodynamics were measured along the way. PA saturation, right atrial saturation, femoral artery saturation were all obtained. Once adequate study has been performed, the catheter was then removed. Both sheaths were flushed and found fine. The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection. There is no LVAO. There is no mitral regurgitation. There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY: ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart. There is a proximal 60% to 70% stenotic lesion. There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY: ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion. The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease. The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY: ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout. There is no evidence of any critical disease. The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS: ,Pulmonary artery pressure equals 61/23 with a mean of 44. Pulmonary artery wedge pressure equals 32. Right ventricle pressure equals 65/24. The right atrial pressure equals to 22. Cardiac output by Fick is 4.9. Cardiac index by Fick is 2.3. Hand calculated cardiac output equals 7.8. Hand calculated cardiac index equals 3.7. On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%. Femoral artery saturation equals 99.1%. Pulse oximetry is 99%. Right atrial saturation is 76.3%. Systemic blood pressure is 166/58. Body surface area equals 2.12. Hemoglobin equals 12.6.,IMPRESSION:,1. Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2. Normal left ventricular function with an estimated ejection fraction of 60%.,3. Biventricular overload.,4. Moderate pulmonary hypertension.,5. There is no evidence of shunt.,PLAN:,1. The patient will be admitted for IV diuresis in light of the biventricular overload.,2. The findings of the heart catheterization were discussed in detail with the patient and the patient's family. There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history. We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3. The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4. The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5. The patient will have an Internal Medicine evaluation regarding the patient's diabetic history. | Angiography & Catheterization | Cardiovascular / Pulmonary | null |
The patient admitted with palpitations and presyncope. | HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause., | Consult - Palpitations & Presyncope | Cardiovascular / Pulmonary | cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart |
Laparoscopic appendectomy. Acute suppurative appendicitis. A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. | PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:, This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain. On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. However, the patient with additional history of loose stools for several days prior to event. Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach. The appendix itself noted to have a significant inflammation about it. There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:, The patient was placed in supine position. After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg. The Veress needle was then removed. A 10 mm trocar was then introduced through this incision into the abdomen. A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant. This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. Through this port, the dissector was utilized to create a small window in the mesoappendix. Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure. Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it. The appendix was then removed from the 12 mm port site and taken off the surgical site. The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated. The base of the appendix was reevaluated and noted to be hemostatic. Aspiration of warm saline irrigant then done and noted to be clear. There was a small adhesion appreciated in the region of the surgical site. This was taken down with blunt dissection without difficulty. There was no evidence of other areas of disease. Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. The instruments were removed from the patient and the port sites were then taken off under direct visualization. The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2. Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet. | Appendectomy Laparoscopic - 1 | Gastroenterology | gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis |
Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring. | PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1. Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: ,Approximately 1000 cc.,CELL SAVER RETURNED: ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain. He had previous lumbar laminectomy at L4-L5. He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable. He is suffering from neurogenic claudication. He was unresponsive to extensive conservative treatment. He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia. He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded. His lumbar spine was then sterilely prepped and draped in the usual fashion. A previous midline incision was extended from approximate level of L3 to S1. This was in the midline. Skin and subcutaneous tissue were debrided sharply. Electrocautery provided hemostasis. ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia. The lumbar fascia was identified and split in the midline. Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1. Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4. Once this was completed, a self-retaining retractor was then placed. With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable. These were readily mobile with digital palpation. A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1. This bone was morcellized and placed on the back table for utilization for bone grafting. The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1. Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained. Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1. The microscope was utilized during this portion of procedure for visualization. There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure. Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5. Once this was identified, foraminotomies were created to allow additional mobility. The wound was then copiously irrigated with antibiotic solution and suctioned dry. Working type screws, provisional titanium screws were then placed at L4-l5. This was to allow distraction and reduction of the spondylolisthesis. These were placed in the pedicles of L4 and L5 under direct intensification. The position of the screws were visualized, both AP and lateral images. They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5. This allowed for additional decompression of the L5 and L4 nerve roots. Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed. Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval. This was taken in sequence up to a 13 mm space. This was then reduced to a 11 mm as it was much more anatomic in nature. Once this was completed, the spacers were then placed on the left side and distraction obtained. Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally. Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried. A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft. There were impacted at the interspace of L4-L5 under direct image intensification. Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried. The provisional screws and plates were removed. This allowed for additional compression along L4-L5 with the cage instrumentation. Permanent screws were then placed at L4, L5, and S1 bilaterally. This was performed under direct image intensification. The position was verified in both AP and lateral images. Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone. The wound was then copiously irrigated with antibiotic solution and suction dried. The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally. A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1. Appropriate cross connecters were applied and the construct was placed over the pedicle screws. They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra. Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory. All connections were tightened and retightened in Torque 2 specifications. The wound was then copiously irrigated with antibiotic solution and suction dried. The dura was inspected and noted to be free of tension. At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors. An 8-inch Hemovac drain was placed exiting the wound. The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin. The remainder of the Hemovac was assembled. Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape. He was turned and taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded. | Laminectomy & Foraminotomy Revision | Orthopedic | null |
A 10 years of age carries a diagnosis of cystic fibrosis | INTERVAL HISTORY:, ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly increased for the prior 4 days. Sputum is not produced. Sinuses are described as clear. He is an eager eater, eating a regular diet of increased calorie and protein. He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half. Belly complaints are denied. He has 2 to 3 bowel movements per day. He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks, A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS: Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL: He is a cooperative school-aged boy in no apparent distress.,HEENT: Tympanic membranes clear, throat with minimal postnasal drip.,CHEST: Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC: Regular sinus rhythm without murmur.,ABDOMEN: Palpated as soft, without hepatosplenomegaly.,EXTREMITIES: Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN. Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION: PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons. He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis. This situation will be looked into with the hope of restarting soon. Other than that the patient seems to be doing well. A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well. Reinforcement of current medication regime was supplied. No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family. Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues. At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines. This is despite the fact that he has an excellent appetite. Mom reports he is taking his enzymes consistently as well as vitamins. He does have problems meeting his goal for resource drinks per day. Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely. A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital. The patient is doing well in school. With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1. Cystic fibrosis.,2. Poor nutritional status.,PLAN: ,1. Give flu vaccine 0.5 mg IM now, this was done.,2. Continue all other medications and treatment.,3. Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4. Needs to augment current high-calorie diet to give more nutrition. To follow advice by a dietician.,5. Continue all the medication treatments before.,6. To continue off and ongoing psychosocial nutritional counseling as necessary. | Cystic Fibrosis | Cardiovascular / Pulmonary | null |
Patient with palpitations and rcent worsening of chronic chest discomfort. | CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn. | Chest discomfort & palpitations - Consult. | Cardiovascular / Pulmonary | null |
A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear. | EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:, There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion. | MRI Shoulder - 4 | Orthopedic | orthopedic, level of the rotator, impinging lesion, rotator interval, retracted tendon, muscular atrophy, partial tearing, tendon, mri, shoulder, rotator, superior, tear, |
Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. | REASON FOR REFERRAL:, The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day. He has no recollection of the event. The following information is obtained from his medical record. On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed." He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual. She thought he was warm and had chills. He later returned to his baseline. He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline. His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination. Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing. Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room. The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours. He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous. He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline. He thought that his memory abilities were similar to those of his peers of his same age. When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time." He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time. So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it. However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems. He denied any missed appointments, any difficulty scheduling and maintaining appointments. He does not have to recheck information for errors. He is able to complete tasks in the same amount of time as he always has. He reported that he has not made additional errors in tasks that he completed. He said he does write everything down, but has always done things that way. He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes. He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age. He remains completely independent in his ADLs. He denied any difficulty with driving or maintaining any activities that he had always participated in. He is also able to handle their finances. He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:, Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener. Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well. The patient reported drinking an occasional glass of wine approximately two days of the week. He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer. He denied any illicit drug use. Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma. He also had right carpal tunnel surgery in 2005 and has cholelithiasis. Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007. No evidence of acute intracranial processes identified. CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy. EEG was negative. Deferential diagnosis was transient global amnesia versus possible seizure disorder. Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:, The patient obtained a law degree from the University of Baltimore. He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time. He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar. He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously. He reported that he repeated math classes "every year of school" and attended summer school every year due to that. He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country. He served also in the U.S. Coast Guard between 1951 and 1953. He has been married for the past 36 years to his wife, Linda, who is a homemaker. They have four children and he reported having good relationship with them. He described being very active. He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test | Neuropsychological Evaluation - 1 | Neurology | null |
Lumbar puncture with moderate sedation. | PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. Her hemolysis seemed to slow down. She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. She had a blood culture, which was also negative. She was empirically started on presentation with the cefotaxime intravenously. Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. Questions were answered to their satisfaction. They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. She was then given Versed 1 mg intravenously by myself. She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. She was then given 20 mcg of fentanyl intravenously by myself. She was placed in the left lateral decubitus position. Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution. She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision. Clear fluid was not obtained initially, needle was withdrawn intact. The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained. The stylette was replaced and the needle was withdrawn intact and bandage was applied. Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable. Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition. | Lumbar Puncture - 1 | Neurosurgery | neurosurgery, moderate sedation, lumbar puncture, needle, lumbar, |
GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests. | PROBLEM: ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland. The patient is not a great historian. Most of the history is obtained through the old history and chart that the patient has with her. According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001. She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting. During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr. A in August 2001. It was assumed that this was caused by biliary dyskinesia. Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use. Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past. | GI Consultation - 2 | Gastroenterology | null |
The patient was exercised according to standard Bruce protocol for 9 minutes. | REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.,IMPRESSION:,1. Good exercise tolerance.,2. Adequate heart rate and blood pressure response.,3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease., | Treadmill Test | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ekg, st depression, maximal heart rate, treadmill test, bruce protocol, blood pressure, heart rate, treadmill, electrocardiogram, |
Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. | CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.,SOCIAL HISTORY: , The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS: | T-Cell Lymphoma Consult | Hematology - Oncology | hematology - oncology, t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck, |
Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity. | REASON FOR CONSULTATION:, Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:, Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.,MEDICATION:, Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:, No known allergies.,REVIEW OF SYSTEMS:, As mentioned above,EXAMINATION:, This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt: 239 | Cardiac Consultation - 4 | Cardiovascular / Pulmonary | null |
Evaluation for chronic pain program | REASON FOR EVALUATION:, | Knee & Back Pain | Orthopedic | null |
A 14-year-old young lady is in the renal failure and in need of dialysis. | PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition. | Peritoneal Dialysis Catheter Insertion | Nephrology | nephrology, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal |
Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA. | PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:, Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:, Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:, The patient was placed in the prone position after general endotracheal anesthesia was administered. The scalp was prepped and draped in the usual fashion. The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. The bone flap was elevated. The ultrasound was then used. The ultrasound showed the tumors directly I believe are in the interhemispheric fissure. We noticed that the dura was quite tense despite that the patient had slight hyperventilation. We gave 4 ounce of mannitol, the brain became more pulsatile. We then used the stealth to perform a ventriculostomy. Once this was done, the brain began to pulsate nicely. We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus. After having done this we then used operating microscope and slight self-retaining retraction was used. We obtained access to the tumor. We biopsied this and submitted it. This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total. After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates. The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. The next step was to close the wound after reapproximating the bone flap. The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. The sterile dressings were applied to the scalp. The patient returned to the recovery room in satisfactory condition. Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa. | Craniotomy - Occipital | Neurosurgery | neurosurgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, |
Holter monitoring - For bradycardia and dizziness. | INDICATION: , Bradycardia and dizziness.,COMMENTS:,1. The patient was monitored for 24 hours.,2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3. There were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4. There was a frequent premature ventricular contraction seen. Between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time. During rest of the monitoring period, there were just occasional premature ventricular contractions seen. No ventricular tachycardia was seen.,5. There were no pathological pauses noted.,6. The longest RR interval was 1.1 second.,7. There were no symptoms reported. | Holter Monitoring | Cardiovascular / Pulmonary | cardiovascular / pulmonary, holter monitoring, bradycardia, bigemini, dizziness, heart rate, interval, predominant, premature, premature ventricular contraction, rhythm, sinus, trigemini, ventricular, bradycardia and dizziness, premature ventricular, monitoring, |
A sample note on serous otitis media | Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay. Children begin to speak some words by 18 months. Children with fluid in both ears can show significant delay in their use of language. In addition, young children learn to pronounce words by hearing them spoken. When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears. Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear. Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly. Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms. Therefore, it is essential that ear infections be rechecked after initial treatment. Usually, the presence of fluid results in a "mild conductive hearing loss." This could be as much as 30% hearing loss overall. After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised. This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays. If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated. The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope. Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted. The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia. | SOM - Serous Otitis Media | ENT - Otolaryngology | ent - otolaryngology, tube, bmt, pet, pressure equalizing tubes, serous otitis media, eustachian tube, ear infections, otitis media, middle ear, hearing loss, ear, children, fluid, drain, eustachian, otitis, media, eardrum, infections, middle, loss, hearingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery | HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history. | Preop Cardiac Consult | Cardiovascular / Pulmonary | null |
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. | REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However, she was complaining of chest pain. She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough. When she did cough, it was nonproductive. While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently, an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease.,2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease.,3. Renal cell carcinoma - She is status post nephrectomy.,4. Hypertension.,5. Anxiety disorder.,6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7. Ongoing tobacco use.,PAST SURGICAL HISTORY,1. Recent and multiple thoracentesis as described above.,2. Bilateral mastectomies.,3. Multiple abdominal surgeries.,4. Cholecystectomy.,5. Remote right ankle fracture.,ALLERGIES:, No known drug allergies.,MEDICATIONS: , At home,,1. Atenolol 50 mg daily,2. Ativan p.r.n.,3. Clonidine 0.1 mg nightly.,4. Compazine p.r.n.,5. Dilaudid p.r.n.,6. Gabapentin 300 mg p.o. t.i.d.,7. K-Dur 20 mEq p.o. daily.,8. Lasix unknown dose daily.,9. Norvasc 5 mg daily.,10. Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:, Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL: She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount. HEENT: She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears. CHEST: Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis. CVS: She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations. GI: No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools. GU: No dysuria, burning with urination, kidney stones, and difficulty voiding. MUSCULOSKELETAL: No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness. NEUROLOGIC: She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS: Her T-max is 99.3. Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL: Somewhat fatigued appearing but in no acute distress.,HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema, exudate, or discharge.,NECK: Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules.,CHEST: Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS: Regular rate and rhythm. No murmurs, gallops or rubs. Normal S1 and S2. No S3 or S4.,ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses. | Metastatic Ovarian Cancer - Consult | Obstetrics / Gynecology | null |
Patient reports a six to eight-week history of balance problems with later fatigue and weakness. | HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this. | Cervical Cord Lesion - Consult | Neurology | null |
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 | null |
Laparoscopic right salpingooophorectomy. Right pelvic pain and ovarian mass. Right ovarian cyst with ovarian torsion. | PREOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,3. 8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED: ,Laparoscopic right salpingooophorectomy.,ANESTHESIA: ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:, None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass. Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice. Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits. There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:, The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity. The pain persisted despite multiple pain medications given in the Emergency Room. The patient reports positive nausea and vomiting. There was no vaginal bleeding or discharge. There was no fevers or chills. Her cultures done in the Emergency Room were pending. The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic. The uterus and left ovary were within normal limits. There was a positive flow noted to bilateral ovaries on ultrasound. Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:, After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty. She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion. Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above. She was prepped and draped in the usual sterile fashion. A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix. The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field. The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed. The vulsellum tenaculum was removed. The weighted speculum was removed. Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold. The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp. The CO2 was then turned on with unoccluded flow and excellent pressures. This was continued till a normal symmetrical pneumoperitoneum was obtained. Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope. Laparoscopic findings are as noted above. A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization. Then, a grasper was used to untorse the ovary. Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system. The right tube and ovary were amputated and noted to be hemostatic. The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag. The ovary was too large to fit completely into the bag. Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst. This was a clear yellow fluid. Then, the bag was closed and the ovary was removed from the suprapubic port. The suprapubic port did have to be extended somewhat to allow for the removal of the ovary. The trocar and sleeve were then placed back into the port. The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic. The pelvis was clear and clean. ,Pictures were obtained. The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6. Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed. Therefore, the peritoneal surface was noted to be hemostatic. Therefore, the camera was removed. All instruments were removed. The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed. The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6. The right flank area was palpated and there was no facial defect noted. The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion. Dressings were changed. The weighted speculum was removed from the patient's cervix. The cervix noted to be hemostatic. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition. | Salpingooophorectomy - Laparoscopic | Obstetrics / Gynecology | null |
Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings. | PREOPERATIVE DIAGNOSIS:, Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:, Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer. She was counseled to undergo laparoscopic staging.,FINDINGS:, During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries. No ascites was present. On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered. She was placed in a low anterior lithotomy position using Allen stirrups. The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine. There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports. The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty. The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed. There were no adhesions underlying the previous vertical midline scar. The 10-mm port was placed in the umbilicus, and the laparoscope was inserted. Remaining ports were placed under direct laparoscopic guidance. Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy. An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum. The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached. Pedicles were sealed and divided with bipolar cutting forceps. Excellent hemostasis was noted. Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery. Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps. The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially. The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally. The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy. The right infundibulopelvic ligament was divided using the bipolar cutting forceps. The mesovarium was skeletonized. A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder. Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring. The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries. The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum. The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device. The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen. The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture. The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released. The umbilical port was removed using laparoscopic guidance. The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl. The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture. The final sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened and taken to the post anesthesia care unit in stable condition. | Laparoscopic Hysterectomy | Obstetrics / Gynecology | obstetrics / gynecology, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar, |
A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate. | HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day. This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52. Dr. X was again consulted from the bedside. We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful. In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care. Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS: T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL: The patient is much more alert appearing than my last examination of approximately 3 weeks ago. He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES: Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR: Reveals an irregularly irregular rhythm.,LUNGS: Have diminished breath sounds but are clear anteriorly.,ABDOMEN: Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES: Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL: The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday. Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000. INR 1.4. Transaminases are continuing to trend upwards of SGOT 546, SGPT 256. Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1. Hypotension. I would aggressively try and fluid replete the patient giving him another liter of fluids. If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2. Increased transaminases. Presumably this is from increased congestion. This is certainly concerning. We will continue to follow this. Ultrasound of the liver was apparently negative.,3. Fever and elevated white count. The patient does have a history of pneumonia and empyema. We will continue current antibiotics per infectious disease and continue to follow the patient's white count. He is not exceptionally toxic appearing at this time. Indeed, he does look improved from my last examination.,4. Ventilatory-dependent respiratory failure. The patient has received a tracheostomy since my last examination. Vent management per PMA.,5. Hypokalemia. This has resolved. Continue supplementation.,6. Hypernatremia. This is improving somewhat. I am hoping that with increased fluids this will continue to do so.,7. Diabetes mellitus. Fingerstick blood glucoses are reviewed and are at target. We will continue current management. This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis. Total critical care time spent today 37 minutes. | Atrial Flutter - Progress Note | Cardiovascular / Pulmonary | cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter, |
Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy. Left adrenal mass, 5.5 cm and intraabdominal adhesions. | PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1. Left adrenal mass, 5.5 cm.,2. Intraabdominal adhesions.,PROCEDURE PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:, None.,DISPOSITION:, The patient was taken to recovery room in stable condition. Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:, This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass. Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall. The spleen and liver were unremarkable. The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. There was no evidence of peritoneal studding or masses. The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. She was placed on a bean bag and secured to the table. The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed. Sterile drapes were applied. Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. Laparoscopy was performed with ___________. At this point, we had a second trocar, which was 10 mm to 11 mm port. Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed. We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia. Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. The colon was further mobilized medially again using gravity to aid in our retraction. After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. Repeat laparoscopy showed no additional findings. The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. The abdominal cavity was desufflated and was reinspected. There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture. At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated. The abdominal cavity was desufflated as stated. The patient was sent to Recovery in stable condition. Postoperative orders were written. The procedure was discussed with the patient's family at length. | Laparoscopic Adrenalectomy | Cardiovascular / Pulmonary | null |
Adenoidectomy and tonsillectomy and lingual frenulectomy. Chronic adenotonsillitis and ankyloglossia. | PREOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,PROCEDURE PERFORMED:,1. Adenoidectomy and tonsillectomy.,2. Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:, Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION: ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A curved hemostat was used to grasp the lingual frenulum. The stat was removed and Metzenbaum scissors were used to free the lingual frenulum. Cautery was used to allow hemostasis. The patient was then turned. McIvor mouth gag was inserted. Tonsils and adenoids were exposed. The patient's right tonsil was first grasped with a curved hemostat. Needle tip cautery was used to free the superior pole of tonsil. The tonsil was then grasped in medial superior aspect with a straight hemostat. The tonsil fascia planes were identified with Bovie dissection along the plane. The tonsil was freed from anterior pillar and posterior pillar. Amputation occurred along the same plane as the patient's tongue. Suction cautery was then used to allow for hemostasis. The patient's adenoids were then viewed with an adenoid mirror. An adenoid curet was used to remove the patient's adenoid tissue. Specimen sent. Suction cautery was used to allow for hemostasis. Superior pole of left tonsil was then grasped with a curved hemostat. Superior pole was freed using needle tip Bovie dissection. Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars. The tonsil was then amputated at the same plane as tongue base. Hemostasis was achieved with using suction cautery. Mouth gag was removed. Dual position and occlusion were tested. The patient was extubated and tolerated the procedure well and sent back to PACU. | Adenoidectomy & Tonsillectomy & Lingual Frenulectomy | ENT - Otolaryngology | ent - otolaryngology, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery |
Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. | CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues. This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort. The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized. One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields). Radiographs are taken, and these fields are marked on the patient's skin. The patient is then transferred to the diagnostic facility and placed on a flat CT scan table. Scans are then performed through the targeted area. The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan. The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures. This volume is then reconstructed in 3-dimensional space. Utilizing the beam's-eye view features, the appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures. Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated. | Conformal Simulation | Hematology - Oncology | hematology - oncology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
Holter Monitor Report | INTERPRETATION:,1. Predominant rhythm is normal sinus rhythm.,2. No supraventricular arrhythmia.,3. Frequent premature ventricular contractions.,4. Trigemini and couplets.,5. No high-grade atrial ventricular block was noted.,6. Diary was not kept.,IMPRESSION:, Frequent premature atrial contractions, couplets, and trigemini., | Holter Monitor Report | Cardiovascular / Pulmonary | cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial, |
Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. | HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70 | Feet & Hand Cramping | Neurology | null |
A 37 year-old female with twin pregnancy with threatened premature labor. | GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL: | Ultrasound OB - 3 | Obstetrics / Gynecology | null |
MRI head without contrast. | EXAM:, MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:, Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla. Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction. There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease. There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size. There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy. There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan. This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution. No abnormal mass effect is identified. There are no findings to suggest active hydrocephalus. No abnormal extra-axial collection is identified. There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation. The region of the pituitary/optic chiasm grossly appears normal. The mastoids and paranasal sinuses are clear.,IMPRESSION:,1. No definite acute findings identified involving the brain.,2. There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes. There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3. Moderate to moderately advanced atrophy. | MRI Head - 1 | Neurology | neurology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic |
Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis. | REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. An ultrasound examination had reportedly been done in the past and the mass is being observed. When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there. The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. She has no weight changes consistent with either hyper or hypothyroidism. There is no family history of thyroid cancer in her family. She has no notable discomfort with this lesion. There have been no skin changes. Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:, Essentially unremarkable. The patient has never been hospitalized in the past for any major illnesses. She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS: ,Currently taking no routine medications. She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. This was done in Tijuana. His mom is from central portion of Mexico. There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY: ,The patient is a junior at Hoover High School. She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL: The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. She was alert and oriented x3 and had an appropriate affect.,HEENT: The head and neck examination is most significant. There is mild amount of facial acne. The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK: There is a slightly visible midline bulge in the region of the thyroid isthmus. A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine. There are some shotty adenopathy in the area. No supraclavicular nodes were noted.,CHEST: Excursions are symmetric with good air entry.,LUNGS: Clear.,CARDIOVASCULAR: Normal. There is no tachycardia or murmur noted.,ABDOMEN: Benign.,EXTREMITIES: Extremities are anatomically correct with full range of motion.,GENITOURINARY: External genitourinary exam was deferred at this time and can be performed later during anesthesia. This is same as too for her rectal examination.,SKIN: There is no acute rash, purpura, or petechiae.,NEUROLOGIC: Normal and no focal deficits. Her voice is strong and clear. There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range. T4 and TSH levels were recorded as normal. Free thyroxine was normal, and the serum pregnancy test was negative. There was no level of thyroglobulin recorded on this. A urinalysis and comprehensive metabolic panel was unremarkable. A chest x-ray was obtained, which I personally reviewed. There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. This will have some impact on the postoperative adjunctive therapy. The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. All of the family's questions have been answered. This is a very anxious and anxiety provoking time in the family. I have made every effort to get the patient under schedule within the next 48 hours to have this operation done. We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy. | Thyroid Mass Consult | Pediatrics - Neonatal | null |
Echocardiogram and Doppler | DESCRIPTION:,1. Normal cardiac chambers size.,2. Normal left ventricular size.,3. Normal LV systolic function. Ejection fraction estimated around 60%.,4. Aortic valve seen with good motion.,5. Mitral valve seen with good motion.,6. Tricuspid valve seen with good motion.,7. No pericardial effusion or intracardiac masses.,DOPPLER:,1. Trace mitral regurgitation.,2. Trace tricuspid regurgitation.,IMPRESSION:,1. Normal LV systolic function.,2. Ejection fraction estimated around 60%., | 2-D Echocardiogram - 4 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve |
CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration. | EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process. | CT Head - 4 | Neurology | neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast, |
DDDR permanent pacemaker. Tachybrady syndrome. A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. | PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection. | Pacemaker - DDDR | Cardiovascular / Pulmonary | null |
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. | CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:, Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. This patient has developed some upper airway congestion in the past day. She has not had any vomiting or diarrhea. Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. This patient has not had any rashes. Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit. Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. There were no complications during pregnancy such as diabetes or hypertension. Prenatal care started at approximately 3 weeks, and mom maintained all visits. She also denies any smoking, alcohol, or drug use during the pregnancy. Mom was GBS status positive, but denies any other infections such as urinary tract infections. She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. After delivery, this patient did not receive antibiotics secondary to "borderline labs." She was jaundiced after birth and received photo treatments. Her discharge bilirubin level was approximately 11. Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad. She specifically denies any blistering, herpetic genital lesions. She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:, Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:, Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION: | Infantile Spasms | Pediatrics - Neonatal | null |
Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. | CHIEF COMPLAINT:, Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. Symptoms improved temporarily, but did not completely resolve. By the end of September, her pain had worsened and she was seen in the emergency room at ABC. Chest x-ray was compatible with pleurisy and she was treated with Percocet. Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea. Eventually, she was seen by Dr. X and noted to have splenomegaly. Repeat ultrasound was done and showed the spleen enlarged at 19 cm. In retrospect, this was not changed in comparison to an ultrasound that was done in September. She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006. Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy. This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:, NONE.,MEDICATIONS: ,1. Estradiol/Prometrium. ,2. Ultram p.r.n. ,3. Baby aspirin. ,4. Lunesta for sleep. ,5. She has been started on iron supplements.,PAST MEDICAL HISTORY: ,1. Tubal ligation in 1986.,2. Possible cyst removed from the left neck in 1991.,3. Tonsillectomy.,4. Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally. She is married and has two children, ages 24 and 20. She works as a project administrator.,FAMILY HISTORY: ,Father is deceased. He had emphysema and colon cancer at age 68. Mother has arrhythmia and hypertension. Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION: ,GENERAL: She is in no acute distress.,VITAL SIGNS: Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT: The oropharynx is benign.,SKIN: The skin is warm and dry and shows no jaundice.,NECK: There is shotty adenopathy in the neck.,CARDIAC: Regular rate without murmur.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES: No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending. CBC was normal last week. PT/INR was normal as well.,IMPRESSION:, Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc. Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells. She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission. I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed. We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts. She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma. After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant. | Mantle Cell Lymphoma - Consult | Hematology - Oncology | null |
Patient with a history of ischemic cardiac disease and hypercholesterolemia. | HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:, Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY: ,Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY: ,Quit smoking in 1996. He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year.,Neurologic: Denies any TIA symptoms.,Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder.,Gastrointestinal: He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees.,General Appearance: He is a middle-aged man who is not in any acute distress.,HEENT: Mouth: The posterior pharynx is clear.,Neck: Without adenopathy or thyromegaly.,Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds.,Heart: Normal S1, S2, without gallops or rubs.,Abdomen: Without tenderness or masses.,Extremities: Without edema.,IMPRESSION/PLAN:,1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today.,2. Hypercholesterolemia. He will continue on the same medication.,3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back. | Ischemic Cardiac Disease - Progress Note | Cardiovascular / Pulmonary | null |
The patient comes in today because of feeling lightheaded and difficulty keeping his balance. | HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist. | Lightheadedness | Neurology | neurology, lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness, |
EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass. | PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Normal colon with no evidence of bleeding.,2. Hiatal hernia.,3. Fundal gastritis with polyps.,4. Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN: ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes. She has been anemic as well with no gross evidence of blood loss. She has had a decreased appetite with weight loss greater than 20 lb over the past few months. After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids. The colonoscope was inserted into the rectum and air was insufflated. The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum. There were no polyps, masses, diverticuli, or areas of inflammation. The scope was then slowly withdrawn carefully examining all walls. Air was aspirated. Once in the rectum, the scope was retroflexed. There was no evidence of perianal disease. No source of the anemia was identified.,Attention was then taken for performing an EGD. The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx. The esophagus was easily intubated and traversed. There were no abnormalities of the esophagus. The stomach was entered and was insufflated. The scope was coursed along the greater curvature towards the antrum. Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______. It was not clear if this represents a healing ulcer or neoplasm. Several biopsies were taken. The mass was soft. The pylorus was then entered. The duodenal bulb and sweep were examined. There was no evidence of mass, ulceration, or bleeding. The scope was then brought back into the antrum and was retroflexed. In the fundus and body, there was evidence of streaking and inflammation. There were also several small sessile polyps, which were removed with biopsy forceps. Biopsy was also taken for CLO. A hiatal hernia was present as well. Air was aspirated. The scope was slowly withdrawn. The GE junction was unremarkable. The scope was fully withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes. We will await the biopsy reports and further recommendations will follow. | EGD & Colonoscopy | Gastroenterology | gastroenterology, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy, |
Invasive carcinoma of left breast. Left modified radical mastectomy. | PREOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:, Invasive carcinoma of left breast.,OPERATION PERFORMED:, Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE: ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition. | Radical Mastectomy | Hematology - Oncology | hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy |
MRI Head W&WO Contrast. | EXAM:, MRI Head W&WO Contrast.,REASON FOR EXAM:, Dyspnea.,COMPARISON:, None. ,TECHNIQUE:, MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist). ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement. There are no diffusion weighted signal abnormalities. There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal. The ventricles and sulci are prominent, but proportionate. Per T2 weighted sequence, there is no hyperdense vascularity. There are no calvarial signal abnormalities. There is no significant mastoid air cell fluid. No significant sinus mucosal disease per MRI.,IMPRESSION:,1. No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses. ,2. No evidence for acute infarction. ,3. Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4. Diffuse cortical volume loss, consistent with patient's age. ,5. Preliminary report was issued at the time of dictation. , | MRI Head | Neurology | neurology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri |
Stage IIA right breast cancer. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. | CHIEF COMPLAINT:, Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS: ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right breast. On 02/10/08, she underwent an ultrasound-guided biopsy. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy. The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative. Therefore it was a T2, N0, M0 stage IIA breast cancer. Of note, at that time she was taking hormone replacement therapy and that was stopped. She underwent radiation treatment ending in May 2008. She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara. She also did not tolerate the Femara and I changed it to tamoxifen. She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy. She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen. When I saw her on 04/28/10, she was really doing quite well with tamoxifen. She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself. She is not going take to any further tamoxifen.,Overall, she is feeling well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits.,CURRENT MEDICATIONS:, Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.,ALLERGIES:, Sulfa, Betadine, and IV contrast.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. Asthma.,2. Hypertension.,3. GERD.,4. Eczema.,5. Status post three cesarean sections.,6. Status post a hysterectomy in 1981 for fibroids. They also removed one ovary.,7. Status post a cholecystectomy in 1993.,8. She has a history of a positive TB test.,9. She is status post repair of ventral hernia in November 2008.,SOCIAL HISTORY: , She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher.,FAMILY HISTORY: ,Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.,PHYSICAL EXAM:,VIT: | Breast Cancer Followup - 1 | Hematology - Oncology | null |
A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. | EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte. | MRI Shoulder - 2 | Orthopedic | orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior |
Revision and in situ pinning of the right hip. | PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS: ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL: ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A small bump was placed underneath her right buttock. The right upper thigh was then prepped and draped in standard surgical fashion. The upper aspect of the incision was reincised. The dissection was carried down to the crew, which was easily found. A guidewire was placed inside the screw with subsequent removal of the previous screw. The previous screw measured 65 mm. A 60 mm screw was then placed under direct visualization with fluoroscopy. The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. The guidewire was removed. The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat. The skin was closed with 4-0 Monocryl. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape. The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery. She should continue toe touch weightbearing on her leg. The wound may be wet in approximately 5 days. The patient should follow up in clinic in about 10 days. The patient is given Vicodin for pain. Intraoperative findings were relayed to the mother. | Pinning - Hip | Orthopedic | orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw, |
CT Abdomen and Pelvis with contrast | EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation. | CT Abdomen & Pelvis - 1 | Nephrology | nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct |
A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever. | CHIEF COMPLAINT AND IDENTIFICATION:, A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough. She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom. She has been taking 1 teaspoon every 6 hours. She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis. She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness. All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots. She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:, Her maternal uncles have asthma. There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts. The family lives in Delano. She lives with her mom and sister. The dad is involved, but the parents are separated. There is no smoking exposure.,PHYSICAL EXAMINATION:, ,GENERAL: The child was in no acute distress.,VITAL SIGNS: Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28. Oxygen saturations 98% on continuous. Off of oxygen shows 85% laying down on room air. The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN: Clear.,HEENT: Pupils were equal, round, react to light. No conjunctival injection or discharge. Tympanic membranes were clear. No nasal discharge. Oropharynx moist and clear.,NECK: Supple without lymphadenopathy, thyromegaly, or masses.,CHEST: Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.,ABDOMEN: Bowel sounds are present. The abdomen is soft. There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY: No inguinal lymphadenopathy. Tanner stage I female.,EXTREMITIES: Symmetric in length. No joint effusions. She moves all extremities well.,BACK: Straight. No spinous defects.,NEUROLOGIC: The patient has a normal neurologic exam. She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive. She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate. Metabolic panel: Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3. White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000. Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress. I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment. She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage. She is being admitted for hypoxemia. I hope that this will resolve overnight, and she will be discharged in the morning. I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course. | Reactive Airway Disease | Pediatrics - Neonatal | null |
Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right fifth metatarsal. | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1. Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2. Arthrodesis, right second, third, and fourth toes with external rod fixation.,3. Hammertoe repair, right fifth toe.,4. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5. Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:, TIVA/local.,HISTORY:, This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion. The patient has a long history of crippling severe rheumatoid arthritis. She has pain with shoe gear and pain with every step. She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief. At this time, she desires attempted surgical reconstruction/correction. The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection. Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril. Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg. The foot was lowered in the operative field. The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint. The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe. In addition, the range of motion was less than 5 degrees of the first ray. There was medial pinch callus and callus on the plantar right second metatarsal. Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length. Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon. Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery. Next, the medial and lateral wound margins were undermined with sharp dissection. The joint capsule was then visualized. Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule. A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade. The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint. In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal. Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head. A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare. Next, the bone was passed out as specimen. The head of the metatarsal had evidence of erosion and eburnation. The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue. This was hindering the range of motion of the joint and was removed. The fibular sesamoid was in the interspace. A lateral release was performed in addition. Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed. The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure. Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint. A small drill hole was made in the central aspect at the base of the proximal phalanx. The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline. A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position. It had an excellent fit and the range of motion again was markedly increased from the preoperative level. Next, the wound was again flushed with copious amounts of saline. The flexor tendon was inspected and was found to be intact plantarly. A #3-0 Vicryl was used to close the capsule in a running fashion. A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature. There was a clavus in the dorsal aspect of the head of the proximal phalanx noted. A linear incision was made over the proximal phalanx approximately 2 cm in length. The incision was deepened with #15 blade down to the subcutaneous tissue. Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint. The tendon was peeled off sharply, proximally, and distally. The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded. The base of the middle phalanx, however, had a normal-appearing cartilage. A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare. Next, the base of the middle phalanx was also resected. A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft. The toe assumed a straight and markedly increased straight position. An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed. The joint was flushed with copious amounts of saline. A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis. A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique. The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated. The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated. The same suture material was used. However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight. Next, attention was directed to the fifth digit, which was found to be contracted as well. A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length. A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected. The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound. A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare. The toe assumed to more rectus position. The reciprocating rasp was used to smooth the all bony surfaces. The joint was again flushed with saline. Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique. The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin. A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head. The incision was deepened with a #15 blade to the subcutaneous tissue. Any small vein traversing subcutaneous layer were ligated with electrocautery. Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively. Next, the dorsal linear capsular incision was made down to the bone with a #15 blade. The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly. A sagittal saw was used to resect all hypertrophic bone. A reciprocating rasp was used to smooth all bony surfaces. Next, the wound was flushed with copious amounts of saline. The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique. A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures. The skin was closed with #5-0 Monocryl in a running subcuticular fashion. The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl. Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated. Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon. The tendon was transected. Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed. Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position. One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds. Betadine-soaked Owen silk was applied to all wounds. Betadine-soaked 4 x 4 splints were applied to all toes. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. All the wires have previously been bent and cut and all were capped. A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied. The patient tolerated the above anesthesia and procedure without complications. She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact. She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c. She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office. She was given emergency contact numbers and standard postoperative instructions. She was given Darco OrthoWedge shoe and a pair of crutches. She was discharged in stable condition. | Bunionectomy & Arthrodesis | Orthopedic | null |
Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography. | PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Saphenous vein graft angiography.,4. Left internal mammary artery angiography.,5. Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery. Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery. A steel guidewire was then inserted through the needle into the vascular lumen without resistance. A small nick was then made in the skin and its pressure was held. The needle was removed over the guidewire. A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. The catheter was then advanced into the left ventricle. The guidewire was then removed. The catheter was connected to the manifold and flushed. LVEDP was then measured and found to be favorable for a left ventriculogram. The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material. LVEDP was then remeasured. Pullback was then performed, which failed to reveal an LVAO gradient. The catheter was then removed. Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was removed. Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. The guidewire was removed. The catheter was connected to the manifold and flushed. The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material. The saphenous vein graft was visualized in several different views. The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material. Right coronary system was evaluated in several different views. Once adequate study has been performed, the catheter was retracted. We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire. Next, a multipurpose catheter was advanced over the exchange wire. The wire was then easily passed into the left subclavian artery. The multipurpose catheter was then removed. LIMA catheter was then exchanged over the wire into the left subclavian artery. The guidewire was removed and the catheter was connected to the manifold and flushed. LIMA graft was then engaged using hand injections of non-ionic contrast material. The LIMA graft was evaluated in several different views. Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance. The sheath was flushed for the final time. The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%. Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection. There is no mitral regurgitation. There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries. There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart. There are luminal irregularities from the mid to distal portion. There is noted to be antegrade flow in the LIMA to LAD graft. There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove. There are minor luminal irregularities throughout. There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:, The RCA is a small vessel with luminal irregularities throughout. The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis. Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch. The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1. Diffusely diseased native vessels.,2. Saphenous vein graft to the obtuse marginal branch is widely patent.,3. Left internal mammary artery graft to the left anterior descending artery is patent.,4. Normal left ventricular function with ejection fraction of 60%.,5. Mildly elevated left-sided filling pressures.,PLAN:,1. The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix. The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2. We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3. Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4. The patient will need to be monitored closely for close lipid control as well as blood pressure control. | Heart Catheterization, Ventriculography, & Angiography | Cardiovascular / Pulmonary | null |
Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee. | PREOPERATIVE DIAGNOSES:,1. Torn anterior cruciate ligament, right knee.,2. Patellofemoral instability, right knee.,3. Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1. Complete tear anterior cruciate ligament, right knee.,2. Complex tear of the posterior horn lateral meniscus.,3. Tear of posterior horn medial meniscus.,4. Patellofemoral instability.,5. Chondromalacia patella.,PROCEDURES PERFORMED:,1. Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2. Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3. Partial medial meniscectomy.,4. Partial chondroplasty of patella.,5. Lateral retinacular release.,6. Open medial plication as well of the right knee.,ANESTHESIA:, General.,COMPLICATIONS:, None.,TOURNIQUET TIME:, 130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint. The patella was noted to be situated laterally past the lateral femoral condyle. There was a tear to the posterior horn of the medial meniscus within the white zone. There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus. There was a complete tear of the anterior cruciate ligament. The posterior cruciate ligament appeared intact. Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.,PROCEDURE: ,On 09/11/03, she was taken to the operating room at ABCD General Hospital. She was placed supine on the operating table. General anesthetic was applied by the Anesthesiology Department. Tourniquet was placed on the proximal thigh and it was then placed in a knee holder. She was sterilely prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. Longitudinal incision was made just medial to the tibial tubercle. The subcutaneous tissue was carefully dissected. Hemostasis was controlled with electrocautery. The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction. They were taken on the back table. The soft tissue debris was removed from the tendons. The ends of the tendons were sewn together using #5 Tycron whip type sutures. The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table. Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee. The knee was inflated with saline solution and operative pictures were obtained. The above findings were noted. A second port site was initiated in the inferomedial parapatellar region. Through this, a probe was placed. Tear in the posterior horn medial meniscus was identified. It was resected using a meniscal resector. It was then further contoured using arthroscopic shaver. Attention was then taken to the lateral compartment. A partial meniscectomy was performed using the resector and the shaver. The posterior periphery of the lateral meniscus was also noticed to be unstable. A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon. There was noted to be excellent fixation. The shaver was then taken into the intrachondral notch. First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint. Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle. Next, a tibial guide was placed through the anterior medial portal. A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament. This tibial tunnel was then drilled using 8 mm cannulated drill. Next, an over-the-top guide was then placed at approximately the 11:30 position. A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm. Next the U shape guide was placed through tibial tunnel into the femur. A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur. It was then pulled out through the tibial tunnel using the You-shaped guide. The tendon was then placed around the wire. The wire was pulled back up through the tibial into the femoral tunnel. A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons. Attention was then pulled through the tibial tunnel. The knee was cycled approximately 20 times. A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft. There was noted definite fixation of the graft. There was no evidence of impingement either in full flexion or full extension. The knee was copiously irrigated and it was then suctioned dry. A longitudinal incision was made just medial to the patellofemoral joint. Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision. Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication. The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture. The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch. She was placed in a DonJoy knee immobilizer. The tourniquet was deflated. It was noted the lower extremity was warm and pink with good capillary refill. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient is guarded. She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension. She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal. She will require one to two more physical therapy to help regain motion and strength to the lower extremity. | Ligament Reconstruction & Meniscus Repair | Orthopedic | null |
Thoracentesis. Left pleural effusion. Left hemothorax. | PREOPERATIVE DIAGNOSIS:, Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:, After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not. | Thoracentesis | Cardiovascular / Pulmonary | cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest, |
Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2. | PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type. | Anterior Cervical Discectomy & Fusion - 5 | Neurosurgery | neurosurgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy |
MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding. | CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice. | MRI L-Spine - Subarachnoid Seeding | Orthopedic | orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness, |
Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis. | CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also.,3. Tricuspid valve and pulmonary valve are structurally normal.,4. There is a mild TR present.,5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec.,6. Intraatrial septum was intact. There is no clot or mass seen.,7. Normal LV and RV systolic function.,8. There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm.,2. Normal LV systolic function., | Transesophageal Echocardiogram - 6 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal |
Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1. | PREOPERATIVE DIAGNOSIS:, Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1. Dural tear, postoperative laminectomy, L4-L5.,2. Laterolisthesis, L4-L5.,3. Spinal instability, L4-L5.,OPERATIONS PERFORMED,1. Complete laminectomy, L4.,2. Complete laminectomy plus facetectomy, L3-L4 level.,3. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5. Posterior spinal fusion, L4 to S1.,6. Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS: ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago. He presented several days later with headaches as well as a draining wound. He was subsequently taken back for a dural repair. For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines. He has fullness in the back of his wound. The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak. The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:, After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7. The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties. The patient was given intraoperative antibiotics. The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level. Full-thickness skin flaps were developed. It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid. Cultures were taken, aerobic, anaerobic, AFB, fungal. Once this was done, the paraspinal muscles were affected from the posterior elements. It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1. It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis. Once this was done; however, the fluid emanating from the dura could not be seen appropriately. Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left. Complete laminectomy at L3 was done. Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen. Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture. A Valsalva confirmed no significant lead after the repair was made. There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation. The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl. After this the standard starting point was made. Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall. Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall. The screws were subsequently placed. Tricortical purchase was obtained at S1 ________ appropriate size screws. Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1. This was done on the right side first. The screw was torqued at S1 appropriately and subsequently at L5. Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4. Neutral compression distraction was obtained on the left side. Screws were torqued at L4, L5, and S1 appropriately. Good placement was seen both in AP and lateral planes using fluoroscopy. Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette. Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix. This was placed in the posterior lateral gutters. DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately. Deep retractors then removed from the confines of the wound. Fascia was closed using interrupted Prolene running suture #1. Once this was done, suprafascial drain was placed appropriately. Subcutaneous tissues were opposed using a 2-0 Prolene suture. The dermal edges were approximated using staples. Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape. The drain was connected appropriately. The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition. No complications arose. | Laminectomy & Facetectomy | Neurosurgery | null |
Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot. | PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise. | Tarsectomy | Orthopedic | orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone |
Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee. | PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital. This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam. Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. Minimal cartilaginous pieces were at the patellar tendon. He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department. A thigh high tourniquet was placed. He is prepped and draped in the usual sterile manner. Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes. Straight incision is carried down through skin and subcutaneous tissue anteriorly. Hemostasis was controlled via electrocoagulation. Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. The inferior pole was freshened up. Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. This was tied over the bony bridge superiorly. There was excellent reduction of the tendon to the patella. Interrupted running #1-Vicryl suture was utilized for over silk. A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum. There was excellent repair. Copious irrigation was carried out. Tourniquet was dropped and hemostasis controlled via electrocoagulation. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing. Digits were warm and no brawny pulses present at the end of the case. The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion. He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair. | Patellar Tendon & Retinaculum Repair | Orthopedic | orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum |
Nephrology Consultation - Patient with renal failure. | REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:, Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease. She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. Her creatinine both at XYZ Hospital and University of A was elevated at 2.4. I do not have the results from the prior years. A repeat creatinine on 08/16/06 was 2.3. The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. She had bladder studies a long time ago. She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. She denies any nonsteroidal antiinflammatory drug use. She denies any other over-the-counter medication use. She has chronic hypokalemia and has been on potassium supplements recently. She is unsure of the dose. ,PAST MEDICAL HISTORY: ,1. Hypertension on and off for years. She states she has been treated intermittently but lately has again been off medications.,2. Gastroesophageal reflux disease.,3. Gastritis.,4. Hiatal hernia.,5. H. pylori infection x3 in the last six months treated.,6. Chronic hypokalemia secondary to chronic diarrhea.,7. Recurrent admissions with nausea, vomiting, and dehydration. ,8. Renal cysts found on a CAT scan of the abdomen.,9. No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease. ,10. Stomach bypass surgery 1975 with chronic diarrhea.,11. History of UTI multiple times recently.,12. Questionable history of kidney stones.,13. History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14. Depression.,15. Diffuse degenerative disc disease of the spine.,16. Hypothyroidism.,17. History of iron deficiency anemia in the past. ,18. Hyperuricemia. ,19. History of small bowel resection with ulcerative fibroid. ,20. Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: , The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005. ,CURRENT MEDICATIONS: ,1. Nexium 40 mg q.d.,2. Synthroid 1 mg q.d. ,3. Potassium one q.d., unsure about the dose. ,4. No history of nonsteroidal drug use.,ALLERGIES: | Nephrology Consultation - 2 | Nephrology | null |
Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias | PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:, The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name: Sigma, model #: 12345, serial #: 123456.,VENTRICLE LEAD:, Model #: 12345, the ventricular lead serial #: 123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:, Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS: ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well. There was no complications. The patient went to recovery in stable condition. Chest x-ray will be ordered. She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care. If you have any questions or concerns, please feel free to contact. | VVIR Permanent Pacemaker Insertion | Cardiovascular / Pulmonary | cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads, |
Left axillary lymph node excisional biopsy. Left axillary adenopathy. | PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:, LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion. An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia. I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition. | Lymph Node Excisional Biopsy | Hematology - Oncology | hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy |
Transesophageal echocardiogram for aortic stenosis. Normal left ventricular size and function. Benign Doppler flow pattern. Doppler study essentially benign. Aorta essentially benign. Atrial septum intact. Study was negative. | INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: ,Procedure and complications explained to the patient in detail. Informed consent was obtained. The patient was anesthetized in the throat with lidocaine spray. Subsequently, 3 mg of IV Versed was given for sedation. The patient was positioned and transesophageal probe was introduced without any difficulty. Images were taken. The patient tolerated the procedure very well without any complications. Findings as mentioned below.,FINDINGS:,1. Left ventricle is in normal size and dimension. Normal function. Ejection fraction of 60%.,2. Left atrium and right-sided chambers are of normal size and dimension.,3. Mitral, tricuspid, and pulmonic valves are structurally normal.,4. Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5. Left atrial appendage is clean without any clot or smoke effect.,6. Atrial septum intact. Study was negative.,7. Doppler study essentially benign.,8. Aorta essentially benign.,9. Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1. Normal left ventricular size and function.,2. Benign Doppler flow pattern.,3. Aortic valve area of 1.3 cm2 planimetry., | Transesophageal Echocardiogram - 3 | Cardiovascular / Pulmonary | cardiovascular / pulmonary, aortic valve, ejection fraction, planimetry, ventricular, transesophageal, echocardiogram, atrial septum, septum intact, transesophageal echocardiogram, aortic stenosis, doppler, aortic, valves |
The patient is 14 months old, comes in with a chief complaint of difficulty breathing. | HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get worse and they drove here to Children's Hospital. He has a history of reactive airway disease. He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time. He has been on albuterol off and on over that period. He has had fever overnight. No vomiting, no diarrhea. Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department. Normal urine output. No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above. No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:, Up-to-date.,BIRTH HISTORY:, The child was full term, no complications, home with mom. No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home. No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL: The child is awake, alert, in moderate respiratory distress.,HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed. I felt the child was dehydrated on examination. We gave 20 mL/kg bolus of normal saline over one hour. The child was given Solu-Medrol 2 mg/kg IV. He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally. Normal heart size. No evidence of pneumothorax. No evidence of focal pneumonia. After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. The child's pulse ox on breathing treatments with 100% oxygen was 100%. Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time. After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia. The child has a normal level of alertness; however, has not had any vomiting here. I spoke with Dr. X, on call for hospitalist service. She has come down and evaluated the patient. We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family. The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES: ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT: ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION: ,Status asthmaticus, hypoxia.,PLAN: ,Admitted to Pediatrics. | Difficulty Breathing - ER Visit | Pediatrics - Neonatal | null |
Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel. | PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet arthropathy with scar tissue.,3. No evidence of instability.,OPERATIVE PROCEDURE PERFORMED,1. Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty.,2. Total laminectomy C3, C4, C5, and C6.,3. Excision of scar tissue.,4. Repair of dural tear with Prolene 6-0 and Tisseel.,FLUIDS:, 1500 cc of crystalloid.,URINE OUTPUT: , 200 cc.,DRAINS: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA:, General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:, Less than 250 cc.,INDICATIONS FOR THE OPERATION: ,This is the case of a very pleasant 41 year-old Caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. Last surgery consisted of four-level decompression on 08/28/06. The patient continued to complain of posterior neck pain radiating to both trapezius. Review of his MRI revealed the presence of what still appeared to be residual lateral recess stenosis. It also raised the possibility of instability and based on this I recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. Based on this, I did total decompression by removing the lamina of C3 through C6 and doing bilateral medial facetectomy and foraminotomy at C3-C4, C4-C5, C5-C6, and C6-C7 with no spinal instrumentation. Operation and expected outcome risks and benefits were discussed with him prior to the surgery. Risks include but not exclusive of bleeding and infection. Infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. There is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. This may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. There is also the risk of a dural tear with its attendant problems of CSF leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. This too may require return to the operating room for evacuation of said pseudomeningocele and repair. The patient understood the risk of the surgery. I told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were also placed by Premier Neurodiagnostics for both SSEP and EMG monitoring. The SSEPs were normal, and the EMGs were silent during the entire case. After completion of the placement of the monitoring leads, the patient was then positioned prone on a Wilson frame with the head supported on a foam facial support. Shave was then carried out over the occipital and suboccipital region. All pressure points were padded. I proceeded to mark the hypertrophic scar for excision. This was initially cleaned with alcohol and prepped with DuraPrep.,After sterile drapes were laid out, incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. Dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of C2 was then identified. There was absence of the spinous process of C3, C4, C5, and C6, but partial laminectomy was noted; removal of only 15% of the lamina. With this completed, we proceeded to do a total laminectomy at C3, C4, C5, and C6, which was technically difficult due to the previous surgery. There was also a dural tear on the right C3-C4 space that was exposed and repaired with Prolene 6-0 and later with Tisseel. By careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at C3-C4, C4-C5, C5-C6, and C6-C7. There was significant epidural bleeding, which was carefully coagulated. At two points, I had to pack this with small pieces of Gelfoam. After repair of the dural tear, Valsalva maneuver showed no evidence of any CSF leakage. Area was irrigated with saline and bacitracin and then lined with Tisseel. The wound was then closed in layers with Vicryl 0 simple interrupted sutures to the fascia; Vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. The patient was extubated and transferred to recovery. | Facetectomy & Foraminotomy | Orthopedic | null |
Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. | PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition. | Subxiphoid Pericardiotomy | Cardiovascular / Pulmonary | cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial |
Psychiatric Consultation of patient with altered mental status. | REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, he became confused and he eloped from the unit. When he was found, he became combative. This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly. There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital. Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications. He reports feeling fine currently, denying any complaints. The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment. She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around. However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety. He also denies any hallucinations or delusions. He endorses problems with insomnia. At home, he takes temazepam. His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:, He denies any prior psychiatric treatment or intervention. However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia. During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily. He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1. Heart transplant in 1997.,2. History of abdominal aortic aneurysm repair.,3. Diverticulitis.,4. Cholecystectomy.,5. Benign prostatic hypertrophy.,ALLERGIES:, MORPHINE AND DEMEROL.,MEDICATIONS:,1. Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2. Imodium 2 mg p.o. p.r.n., loose stool.,3. Calcium carbonate with vitamin D 500 mg b.i.d.,4. Prednisone 5 mg p.o. daily.,5. Bactrim DS Monday, Wednesday, and Friday.,6. Flomax 0.4 mg p.o. daily.,7. Robitussin 5 mL every 6 hours as needed for cough.,8. Rapamune 2 mg p.o. daily.,9. Zoloft 50 mg p.o. daily.,10. B vitamin complex daily.,11. Colace 100 mg b.i.d.,12. Lipitor 20 mg p.o. q.h.s.,13. Plavix 75 mg p.o. daily.,14. Aricept 5 mg p.o. daily.,15. Pepcid 20 mg p.o. daily.,16. Norvasc 5 mg p.o. daily.,17. Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:, The patient is a retired paster and missionary to Mexico. He is still actively involved in his church. He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:, He is an average-sized white male, casually dressed, with wife and son at bedside. He is pleasant and cooperative with good eye contact. He presents with paucity of speech content; however, with regular rate and rhythm. He is tremulous which is worse with posturing also some increased motor tone noted. There is no evidence of psychomotor agitation or retardation. His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content. His thoughts are circumstantial but logical. He defers most of his responses to his wife. There is no evidence of suicidal or homicidal ideations. No presence of paranoid or bizarre delusions. He denies any perceptual abnormalities and does not appear to be responding to internal stimuli. His attention is fair and his concentration impaired. He is oriented x3 and his insight is fair. On mini-mental status examination, he has scored 22 out of 30. He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s. On category fluency, he was able to name 17 animals in one minute. He was unable to draw clock showing 2 minutes after 10. His judgment seems limited.,LABORATORY DATA:, Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000. Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:, MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1. Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2. Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3. Depressive disorder, not otherwise specified. | Psych Consult - Altered Mental Status | Psychiatry / Psychology | null |
Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability | COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:, The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability. He is a 43-year-old married, white male who came unaccompanied to the evaluation. He drove himself suggesting that he drives regularly. He reportedly has been on Disability since around 2002. He was a good historian, freely offering information. He was dressed and groomed casually, yet neat and appropriate in appearance. He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning. No censorship of data was indicated. ,PRESENT PROBLEMS:, The claimant described his recent problems as, "serious depression. Very hard to concentrate. Very short tempered. Usually distracted." ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago. He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because "I had a breakdown and ended up in the hospital. They said that I wasn't reliable enough and laid me off." Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed. ,The claimant has had significant emotional problems since around 1997. He was first hospitalized in that year and has been hospitalized five more times since then. The last hospitalization was last month in Atlanta, Georgia. He has tried to overdose in the past as well as cut his wrist. He even had to undergo electroconvulsive therapy in 2001, because of depression. He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident. Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d. He is not involved in outpatient therapy. ,PERSONAL, FAMILY AND SOCIAL HISTORY:, The claimant indicated that he graduated from high school in regular classes. He did have to repeat the kindergarten because he was too young. He worked for about 10 years at a company in Massachusetts. He was not advancing on that job and therefore quit. He has had three subsequent jobs and a number of emotional problems since. He indicated usually getting along with others but stated, "I had trouble taking direction from someone younger than me. I resent getting nagged at. I'd get angry or just seethe." He has been let go from his last two jobs because of emotional issues. ,The claimant was married the first time for five years. He has no children. He now lives at home with his wife., ,The claimant denied any legal problems. He suggested that his mother had bipolar disorder. He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs. He stopped drinking in 1997. Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:, The claimant described his typical day as follows, "I usually get up about 7:00 to 7:30. Have breakfast. Take a shower about 8:30. Do errands. Me and my wife are out of the house by 9:00. Check e-mail at the library. I like the computer. We have lunch 11:30 or 12:00. Do errands or watch talk shows or I'll read. I love to read. Around 5:00 to 5:30, have supper. Watch the news, game shows. In bed by 10:00." He will help with vacuuming, doing the dishes or yard work. His wife does most of the house cleaning. He does no cooking. He and his wife get out every day usually for three or four hours. He has a neighbor next door that he will see twice a week. He used to go to the gym but has not been in a few weeks. No other family contact was described and he does not go to church. When asked what he enjoys he stated, "read, use my computer or go ride my bike.", ,MENTAL STATUS EVALUATION:, On interview, the claimant looked his stated age of 43 years. He was tall in stature and thin in weight. He was neat and clean in appearance. Posture was somewhat tense but psychomotor activity was not remarkable. Eye contact was fleeting with fair social skills evident. Facial expression was tense and affect was restricted with little animation noted. General mood appeared dysphoric. Speech was clear, coherent, logical, goal-directed and relevant. He was cooperative in attitude toward the examiner. He described his recent mood as, "cloudy, gray because we've got a lot of personal problems right now. I'm frustrated because I don't know where things are going." He described some problems with falling asleep and staying asleep at night as well as decreased energy level. He denied appetite disturbance. He has lost interest in some activities suggesting mild anhedonia. He has trouble with attention and concentration stating, "I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder." He has thoughts of suicide about once or twice a week and has often fled situations in the past. He stated, "I try to keep myself from running away." He denied any plan or intent for suicide. He suggested significant anxiety problems as well. He stated, "I'm dealing with pedophilia. I try to time it so that I don't go to a store with lots of people around. If there is people I get real edgy, heart pounds, shortness of breath. A lot of chest discomfort." He has these panic symptoms quite regularly and they have occurred ever since 1997. That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail. No phobic processes were suggested. No psychotic symptoms were revealed. He denied hallucinations and no delusional material was elicited. Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres. He evidenced adequate memory for both recent and remote events. He was able to recall 3 of 3 words after a 1 minute and 10 minute delay. Fair sustained attention and concentration skills were shown. He was able to spell a word backward and performed a serial 7 subtraction task affectively. Basic calculation skills were intact and no language-based dysfunction was noted. Social judgment was also intact as he gave a good response to finding a wallet in the street, "find who the owner was, bring it to the police station or contact the person," and to seeing smoke in a theater, "Get a hold of staff so they could evacuate." Adequate conceptual abilities was shown with similarity comparisons. Somewhat limited abstraction was shown with proverb interpretation, glass houses, "don't do anything you're not supposed to do." Premorbid intellect is estimated to be at least in the average range. Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I: Major Depression, recurrent, moderate. Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:, Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities. He continues to show significant problems with depression and anxiety. He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations. He relies on his wife to take care of most all household task. He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:, The claimant was strongly encouraged to get some additional help for his emotional problems. He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned. | Mental Status Evaluation | Psychiatry / Psychology | null |
Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. | PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet applied to the upper arm. The extremity was prepped in a usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine. A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint. The tourniquet was released. Circulation returned to the fingers. The patient then was allowed to awaken and left the operating room in good condition. | Ganglion Excision | Orthopedic | orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion |
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology. | REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY: ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:, Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY: ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT: Atraumatic.,NECK: Soft and supple.,LUNGS: Bilaterally diminished.,HEART: Regular.,ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:, Have her admitted to the medical service for treatment of her hyponatremia. | Air Under Diaphragm - Consult | Gastroenterology | null |
Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium). | PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C3-4.,2. Arthrodesis with anterior interbody fusion, C3-4.,3. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT: ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS: ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: ,Less than 100 mL.,CONDITION: ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION: ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop. Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening. About two days ago, he started noticing weakness on the left arm. The patient also noted shuffling gait. The patient presented to a family physician and was referred to Dr. X for further evaluation. Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine. MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes. Based on these findings, I recommended decompression. The patient was started on Decadron at 10 mg IV q.6h. Operation, expected outcome, risks, and benefits were discussed with him. Risks to include but not exclusive of bleeding and infection. Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function. Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient. There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics. However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation. This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed. There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele. This too can compromise airway and may require return to the operating room for repair of the dural tear. There is also potential risk of injury to the esophagus, the trachea, as well as the carotid. The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. No monitoring leads were placed. The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. Localizing x-ray verified the marker to be right at the C3-4 interspace. Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath. The prevertebral fascia was identified. Localizing x-ray verified another marker to be at the C3-4 interspace. Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out. There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur. The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side. By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed. Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder. With this completed, the Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant with its interior packed with Vitoss was then tapped into place. An 18-mm plate was then screwed down with four 14 x 4.0 mm screws. The area was irrigated with saline, with bacitracin solution. Postoperative x-ray showed excellent placement of the graft and spinal instrumentation. A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond. The catheter was anchored to the skin with a nylon 3-0 stitch. Dressing was placed only on the exit site of the drain. C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities. | Anterior Cervical Discectomy & Fusion - 4 | Neurosurgery | null |
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 | null |
Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. The patient is here for followup visit and chemotherapy. | CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1. Posttransplant lymphoproliferative disorder.,2. Chronic renal insufficiency.,3. Squamous cell carcinoma of the skin.,4. Anemia secondary to chronic renal insufficiency and chemotherapy.,5. Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2. Chronic renal insufficiency.,3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support.,4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today.,5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him. | Posttransplant Lymphoproliferative Disorder | Hematology - Oncology | hematology - oncology, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative, |
The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. | IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height. He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:, Prior to admission, we do not have that information. He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY: ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude: The patient is unresponsive.,Appearance: He is lying in bed in the fetal position with a blanket over his head.,Psychomotor: Catatonic.,EPS/TD: Unable to assess though his limbs are quite contracted.,Affect: Unresponsive.,Mood: Unresponsive.,Speech: Unresponsive.,Thought Process And Thought Content: Unresponsive.,Psychosis: Unable to elicit information to make this assessment.,Suicidal/Homicidal: Also unable to elicit this information.,Cognitive Assessment: Unable to elicit.,Judgment And Insight: Unable to elicit.,Assets: The patient is young.,Limitations: Severe decompensation.,FORMULATION: ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I: Psychosis, NOS.,AXIS II: Deferred.,AXIS III: Dehydration.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1. Stabilize medically from the dehydration per internal medicine.,2. Medications, milieu therapy to assist with re-compensation. | Psych Consult - Psychosis - 2 | Psychiatry / Psychology | null |
Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment. | PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1. DePuy Ultima calcar stem, size 3 x 45.,2. Bipolar head 28 x 43.,3. Head with +0 neck length.,4. Distal centralizer and cement restrictor.,5. SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS: ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. The lesser trochanter was intact. The fracture site was noted to show abnormal pathological tissue with grayish discoloration. The quality of the bone was also pathologically abnormal with soft trabecular bone. The abnormal pathological tissues were sent along with the femoral head to pathology for assessment. Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. She denied any history of fall or trauma. The presentation was consistent with pathological fracture pending tissue assessment. Indication, risks, and benefits were discussed. Treatment options were reviewed. No guarantees have been made or implied.,PROCEDURE: ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. The left lower extremity was prepped and draped in a standard sterile fashion. Time-out procedure was called. Antibiotics were infused.,A standard posterolateral approach was made. Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. This was then incised along the line of the incision. Hemostasis was achieved. Charnley retractor was positioned. The trochanter was intact. The gluteus medius was well protected with retractor. The piriformis and minimus junction was identified. The minimus was also reflected along with the medius. Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. Similarly, L-shaped capsulotomy was performed. A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair. Fracture site was exposed. The femoral neck fracture was noted to be very low-lying basicervical type. Femoral head was retrieved without any difficulty with the help of a corkscrew. The head size was measured to be 43 mm. Bony fragments were removed. The acetabular socket was thoroughly irrigated. A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. This was sent to the pathology. The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. An L-shaped osteotomy was performed in order to accept the calcar prosthesis. The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. There was no calcar superior to the lesser trochanter. The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. Hemostasis was achieved. Now, the medullary canal was entered with a canal finder. The fracture site was well exposed. Satisfactory lateralization was performed. Attention was for the reaming process. Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. Appropriate anteversion was positioned. The anteversion was marked with a Bovie to identify subsequent anteversion during implantation. The bony edges were trimmed. The calcar implant with 45 mm neck length was fit in the host femur very well. There was no evidence of any subsidence. At this point, trial reduction was performed using a bipolar trial head with 0 neck length. The relationship between the central femoral head and the greater trochanter was satisfactory. The hip was well reduced without any difficulty. The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. The shuck was less than 1 mm. Leg length was satisfactory in reference to the contralateral leg. Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees. After verifying the stability and range of motion in all direction, trial components were removed. The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. At this point, 2 batches of SmartSet cement with antibiotics were mixed. The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected. Centralizer was positioned. The cement restrictor was inserted. Retrograde cementing technique was applied once the canal was dried. Using cement gun, retrograde cementing was performed. The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. The excess cement was removed with the help of a curette and Freer elevator. All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head. Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. Range of motion and stability was as above. Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster. Satisfactory reinforcement was achieved with the #5 Ethibond. The wound was thoroughly irrigated. Hemostasis was achieved. The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl. The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures. Skin was approximated with staples. Sterile dressings were placed. Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noted. | Cemented Hemiarthroplasty & Biopsy | Orthopedic | null |
Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section). Left thoracotomy with resection of posterior mediastinal mass. | PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition. | Mediastinal Mass Resection | Cardiovascular / Pulmonary | cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal, |
Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee. | PREOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,POSTOPERATIVE DIAGNOSIS: , Internal derangement, left knee.,PROCEDURE PERFORMED:, Arthroscopy of the left knee with medial meniscoplasty.,ANESTHESIA: ,LMA.,GROSS FINDINGS: , Displaced bucket-handle tear of medial meniscus, left knee.,PROCEDURE: , After informed consent was obtained, the patient was taken to ABCD General Hospital Operating Room #1 where anesthesia was administered by the Department of Anesthesiology. The patient was then transferred to the operating room table in supine position with Johnson knee holder well-padded. Tourniquet was placed around the left upper thigh. The limb was then prepped and draped in usual sterile fashion. Standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed. Patellofemoral joint showed frequent chondromalacia. Examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus. The medial femoral condyle and medial tibial plateau were unaffected. Intercondylar notch examination revealed an intact ACL and PCL stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus. The femoral condyle and tibial plateau were all stable to probing. Attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors. A shaver was then used to smooth all the edges until the margins were stable to probing.,The knee was then flushed with normal saline and suctioned dry. 20 cc of 0.25% Marcaine was injected into the knee and into the arthroscopy portals. A dressing consisting of Adaptic, 4x4s, ABDs, and Webril were applied followed by a TED hose. The patient was then transferred to the recovery room in stable condition. | Knee Arthroscopy & Medial Meniscoplasty | Orthopedic | orthopedic, arthroscopy, meniscoplasty, derangement, internal derangement, knee, displaced bucket handle tear, femoral condyle, tibial plateau, medial meniscoplasty, medial meniscus, medial |
Desires permanent sterilization. Laparoscopic bilateral tubal occlusion with Hulka clips. | PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS: ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size. There were no adnexal masses appreciated. The vulva and perineum appeared normal. Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally. There was a functional cyst on the left ovary. There was filmy adhesion in the left pelvic sidewall. There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac. The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis. The liver was visualized and appeared normal. The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization. She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. She was then prepped and draped and placed in the dorsal lithotomy position. A bimanual exam was performed and the above findings were noted. Prior to beginning the procedure, her bladder was drained with a red Robinson catheter. A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum. The cervix was dilated so that the uterine elevator could be placed. Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made. The Veress needle was then inserted and using sterile saline ______ the pelvic cavity. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope. A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty. Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube. A second Hulka clip was then placed across the entire diameter just proximal to this. There was good hemostasis at the fallopian tube. The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle. A second Hulka clip was placed just distal to this again across the entire diameter. Good hemostasis was obtained. At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic. The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed. The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl. The suprapubic incision was then closed with Steri-Strips. The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic. The patient tolerated that procedure well. The sponge, lap, and needle counts were correct x2. She will follow up postoperatively for followup care. | Bilateral Tubal Occlusion - Laparoscopic | Obstetrics / Gynecology | obstetrics / gynecology, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips, |
Followup for polycythemia vera with secondary myelofibrosis. JAK-2 positive myeloproliferative disorder. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. | DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.,The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.,3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems. | Polycythemia Vera Followup | Hematology - Oncology | hematology - oncology, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis, |
The patient admitted with palpitations and presyncope. | HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause., | Consult - Palpitations & Presyncope | Cardiovascular / Pulmonary | cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart |
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